HEMATOLOGIC TESTS

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 HEMATOLOGIC TESTS
• Hematopoiesis is defined as the formation and maturation of

blood cells and their derivative.

• It takes place primarily in the bone marrow.

• The hematopoietic system consists of three primary cell

components:

 Leukocytes (WBC),

 Thrombocytes (Platelets), and

 Erythrocytes (RBC)
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 Patient Encounter: Part 1

• You are rounding on an internal medicine advanced

pharmacy practice experience with the ICU team.
When preparing for rounds, note that there was a
new admission last night—an Olympic bicyclist who
was struck by a car. Begin reviewing the pt’s
laboratory data in preparation for rounds
• On admission to the hospital last night, pt X had the
following CBC:
 WBC: 7,200 cells/mm3Hct: 30%
 RBC: 3.7 × 106 cells/mm3 MCV: 92 μm3/cell
– Hgb: 10 g/dL MCH: 30 pg/cell
– MCHC: 35 g/dL
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Discussion Questions—Part 1:
• What do the above abbreviations represent?
• Which of the laboratory values are
abnormal?
• What type of anemia is present?
• What is the most likely cause of the anemia
in this pt?

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 Part 2

• Several days later the pt begins to spike fevers. CBC, chest x-ray,
UA, and blood and urine cultures are done to look for possible
sources of infection. The CBC results are as follows: CBC with
differential
• WBC: 17,900 cells/mm3
• WBC differential
-Segs: 65%-Bands: 10%
-Lymphocytes: 17%-Monocytes: 5%
-Eosinophils: 2% -Basophils: 0.5 %
• Hgb: 14 g/dL
• Hct: 42%
• RBC: 4.2 × 106 cells/mm3
– MCV: 90 μm3/cell - MCH: 31 pg/cell
– MCHC: 36 g/dL
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Discussion Questions—Part 2:
• What abnormalities are noted in the CBC?
• What is a “left shift,” and what does it
indicate? Is a left shift present?
• What is the most likely cause of these
abnormalities?
• What follow-up actions/treatments will
probably be needed as a result of these
abnormal laboratory tests?

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 Complete Blood Count (CBC)

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 Complete Blood Count (CBC)
• The CBC (hemogram) is an extremely common laboratory
test that provides values for:
 WBCs, RBCs, Hgb, Hct and red cell indices (MCV, MCH, and MCHC)

• In addition, some laboratories may also include platelet

count and WBC differential
• The findings in the CBC give valuable diagnostic information
about the hematologic and other body systems, prognosis,
response to treatment, and recovery.

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 White Blood Cells (Leukocytes)

• Reference values (3,200 - 11,300 cells/mm3)

• WBC includes neutrophils, eosinophils, basophils,

monocytes/macrophages, lymphocytes &plasma cells

1. Neutrophils (segs and bands)

• Polymorphonuclear [PMN] leukocytes or segs primarily

function as defenses against bacterial infection.

• Neutrophils mature more quickly under stress full condition and

have life time of 10 days.

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• Once in the peripheral blood, it can be in the
Circulating pool (CP) or
 Marginated pool (MP)—approx. 50% attached arround the
blood vessel wall

• Cells in MP are not counted in CBC

• Shift from MP to CP can occur with stress, trauma,
catecholamines, etc
• This results in transient leucocytosis which lasts 4 to 6
hours
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 Neutrophils present in two forms

Segmented neutrophils (segs) 40-70% of WBC

Bands (immature neutrophils) ≤ 5% of WBC

• ‘Left shift’ is seen as increase in the number of

bands and is common with acute infection or
leukemia.

• Main function of nutrophils is to locate, ingest and

kill bacteria and other foreign invaders
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 Causes of neutrophilia (increase in WBC)

Phatophysiologic
Acute bacterial infection
Certain viruses and fungi
Inflammatory responses and tissue necrosis (burns, snake bite,
tumor, MI)
Metabolic intoxication (DM, DKA,)
• Drugs
Steroids -Lithium
• Physiologic
Pseudoneutrophilia (shift from MP to CP) due to
catecholamines and acute stress
Other inflammatory responses (neoplastic growth, or
metabolic disorders, RA, vasculitis, gout)
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 Causes of Neutropenia

 Decreased production of WBC ( bone marrow dx,

malignancies, and chemotherapy drugs)
 Increased neutrophil destruction (overwhelming
infection, certain bacteria, and immune reaction)
 Pseudoneutropenia (shift from CP to MP) --viral
infection and hypothermia

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 Absolute neutrophil count (ANC)

• is the total number of circulating segs and bands

and is calculated from the equation:
ANC = WBC × [(% segs + % bands)/100]

• The risk of infection increases dramatically as the

ANC decreases.
• An ANC less than 500/mm3 is associated with a
substantial risk of infection
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 2. Eosinophils
• Life span 14 days -- segmented

• Spends little time in blood before it locates in skin,

GIT, respiratory tract and only 1% of mature cells are
located in blood.
• Function as phagocytes but appear to be less potent
than neutrophils.
• Drawn to sites of hypersensitivity rxn by mast cell
chemotactic factors.
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• Eosinophilic granules contain histamine (1/3 of all the
histamine in the body).
• This test is used to diagnose:
– Allergic infections,
– Assess severity of infestations with worms and other large parasites,
and
– Monitor response to treatment.

• Often found in the sputum of asthmatics

• Play a role in pathogenesis of lung dx and parasitic
infections.
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 3. Basophils
• Least common of WBCs (< 2%)

• Nucleus does not always segment

• Increases in response to conditions that cause
increase eosinophils ( parasitic infection,
hypersensitivity)
• Basophil counts are used to study chronic
inflammation.
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 Basophilia
• Basophilia (increased count) > 50/mm3 is
commonly associated with the following:
a. Granulocytic (myelocytic) leukemia
b. Acute basophilic leukemia
c. Myeloid metaplasia, myeloproliferative disorders
d. Hodgkin’s dx

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 4. Monocytes / Macrophages
• Monocytes are peripheral cells in transit from the BM to
tissues.
• Although not common in circulating blood, they stay about 70
hrs in blood.
• Become macrophages in tissue under influence of local
factors.
 Liver, spleen, lymph nodes, microglial (CNS) cells, skin, and
bone
• They live for several months or longer in tissues.
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• Primary role is phagocytosis, and in ingesting cellular derbis

and immunity.

• Become activated when direct contact with microorganisms

occur.

• The most common causes of monocytosis are bacterial

infections, tuberculosis, subacute bacterial endocarditis, and

syphilis.

• They remain increased even after successful therapy of

infection, thus are not good indicators of prognosis.

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 5. Lymphocytes
Reference range: 20%-45% (1500–4000 cells/mm3)
• Lymphocytes are divided into two categories, T and B
cells.

• Main functions are antigen recognition and

immune response.

• Life span varies (up to 2yrs)

• Can pass back and forth between blood and tissue.

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B lymphocytes (B-cells)
• Are most effective against bacteria & their toxins plus some viruses.
• Are produced and matured in bone marrow
• B cells are responsible for humoral immunity (antigen-antibody
response)
T lymphocytes (T-cells)
• T cells display cell-mediated immunity
• Recognizes & destroys body cells gone awry, including virus
infected cells and cancer cells
• There two types T cells in peripheral blood:
 Suppressor T cells (CD8)
 Helper T-cells (CD4) predominate

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 Lymphocyte count increase (lymphocytosis):
(> 4,000 cells/mm3)
 Influenza -Pertussis
 TB -Mumps
 Cytomegalovirus infection - Lymphatic leukemia
 Infectious hepatitis -Viral pneumonia
Lymphocyte count decrease (lymphopenia (<1,000
cell/mm3)
 HIV/AIDS - Chemotherapy
 Bone marrow suppression
 Aplastic anemia - Steriods
 Neurologic disorders - Multiple sclerosis
 Myasthenia gravis
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 Types of WBC Reference values:
% (absolute count)

Neutrophils 40-70% (3000–7000/mm3)

Bands 0-5%

Eosinophils 0-6%

Basophils 0-1%

Lymphocytes 20-45% (1500–4000 /mm3)

Monocytes
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Interpreting the WBC
• What is the total WBC ?
– If elevated, what type of WBC is eleveted?
 Is it the neutrophils, eosinophils, lymphocytes, basophils,
or monocytes?
• Marked leukocytosis is usually due to neutrophils
and lymphocytes
– If neutrphils are causing the leukocytosis, compare its %
to total WBC
• The % of neutrophils indicates the severity of
infection
• The total WBC reflects the quality of the immune
system
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Case 1 : 85 yrs old female with pneumonia:
 Total WBC 11,500
 Neutrophils 80% (9,200), bands 5%
• Severe bacterial infection in patient with low
quality of immunity (poor prognosis).
Case 2: 5 yrs old male with pneumonia
– WBC 18,000
– Neutrophils 60% (10,800), Band 10%
• Mild infection but the child’s immunity is over
active (excellent)- good prognosis.

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Case 3: 20 yrs old man admitted following MCA
 WBC 14,500 - neutrophils 75%, and
 bands 1%
• Stress induced shift from marginalized pool to
circulating pool causing transient leukocytosis.
Case 4: 10 yrs old male admitted for pneumonea
– WBC 16,000 - Neutrophils 75%
– Bands 5% - Eosinophils 1%
– Lymphocytes 10% - Monocytes 3%
• Mild to moderate infection in patient with good
immunity (good prognosis)  good prognosis.
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 Platelet Count (Thrombocytes)

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 Platelet Count (Thrombocytes)
Reference Range (150,000-450,000/mm3 SI 150-

450 × 109/L)
• Platelets are a critical element in blood clot
formation.
• The risk of bleeding is low unless platelets
fall below 20,000 to 50,000/mm3

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 Increased Platelets
Thrombocytosis /Thrombocythemia is asymptomatic
• Infection
• Malignancies,
• Splenectomy,
• Chronic inflammatory disorders (e.g, R.A)
• Polycythemia vera,
• Hemorrhage,
• Iron deficiency anemia,
• Myeloid metaplasia
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Decreased Platelets (thrombocytopenia)
• Decreased platelet counts or thrombocytopenia
may lead to petechiae, ecchymosis, and
spontaneous hemorrhage.
• Due to defect in production, increased
sequestration, or accelerated destruction
Autoimmune disorders such as idiopathic
thrombocytopenic purpura (ITP)
Aplastic anemia,
Radiation and chemotherapy,
Space-occupying lesion in the bone marrow, bacterial
or viral infections, and
Use of heparin or valproic acid
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 RED BLOOD CELLS
(Erythrocyte Studies)

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 RBC or Erythrocyte Count

• Reference Range
 Male: 4.2-5.9 × 106 cells/mm3
 Female: 3.5-5.5 × 106 cells/mm3

• Produced in bone marrow, released in to peripheral

blood, circulate in blood app. 120 days and cleared by
the reticuloendothelial system.

• Primary function of RBC is transportation of gas (O2 or

CO2)
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Increased RBC (Erythrocytosis) Decreased RBC
• 10 : polycythemia vera • Occurs in anemia
– increased production in BM  Decreased production
• 20 to:  Increased destruction
 Living at high altitude, (hemolysis)
 Strenuous exercise  Blood loss
 Chronic lung or heart dx
 Tobacco use/ CO

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 Hemoglobin (Hgb)

Normal Range
Male: 14-18 g/dL SI 8.7-11.2 mmol/L
 Female: 12-16 g/dL SI 7.4-9.9 mmol/L

 Hgb is the oxygen-carrying compound found in the

RBCs
 Depends on number of RBC and the amount of Hgb in each
RBC
 Hgb determination is used in evaluation of anemia.
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• The Hb determination is part of a CBC.
• It is used to screen for disease associated with anemia,
to determine the severity of anemia, to monitor the
response to treatment for anemia, and to evaluate
polycythemia.
• The critical Hb value is <5.0 g/dL , a condition that leads
to heart failure and death.
• A value >20 g/dL leads to clogging of the capillaries as a
result of hemoconcentration.
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Increased in: Decreased in:

 Dx such as polycythemia  Anemia of all types,

particularly IDA
vera, COPD, CHF
 Pregnancy
 Chronic smokers
 Regular vigorous exercise  Blood loss and hemolysis

 Live at high altitudes  Fluid replacement, or

increased fluid intake
 Falsely elevated WBC or
dehydration

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 Hematocrit (Hct)/Packed Cell Volume (PCV)

Reference Range
Male: 39%-50%
Female: 33%-45%

• The Hct describes the volume of blood that is

occupied by RBCs.
• It is expressed as a percentage of total blood volume

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• Increased in • Decreased in

 Polycythemia vera,  All types of anemias,

 Blood loss,
 COPD,
 High altitudes  Hemolysis,

 Dehydration and  Pregnancy,

 Cirrhosis,
 Shock
 Hyperthyroidism, and
 Leukemia

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 The rule of three

Hgb = 3 times the RBC

Hct = 3 times Hgb
• This rule applies to normocytic & normochronic erythrocytes

only.

• Useful to detect laboratory errors in measuring the Hgb, Hct

and RBC.

• The same underlying conditions cause an increase or

decrease in each of these three tests.

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 RBC indices
Mean Corpuscular Volume (MCV) or Mean Cell Volume

Reference Range (80-100 μm3/cell) SI 76-100 fl*

• The MCV provides an estimate of the average volume of

one erythrocyte.

• It is the average size of single RBC

MCV = Hct/RBC count

*femtoliter(fl)= 10-5l

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 • Cells with an abnormally large MCV are classified as
macrocytic
• An increase in MCV is associated with
Folate or vitamin B12 deficiency,
Conditions like alcoholism, chronic liver dx, anorexia,
hypothyroidism, and
Use of medications such as valproic acid, zidovudine,
stavudine and antimetabolites.
Infants and new born
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 • Conversely, cells with a low MCV are referred to
as microcytic RBC
 Result from IDA, hemolytic anemia, lead
poisoning, and thalassemia
• Normocytic RBCs have an MCV that falls within
the normal range
 Current bleeding, anemia of chronic diseases

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 Mean Corpuscular/Cell Hgb (MCH)

Reference Range: (26-34 pg/cell)

• The MCH indicates the average weight of Hgb in
the RBC.
• This index is of value in diagnosing severely anemic
pts.
• Cells with a low MCH are pale in color and are
referred to as hypochromic.
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• Cells with an increased MCH are hyperchromic,
and cells with normal amounts of Hgb are
normochromic
• Elevated MCH
Folate or vit. B12 deficiency
Hyperlipidemia pts, falsely elevated

• Decreased MCH is associated with IDA

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 Mean Corpuscular/Cell Hgb Concentration (MCHC)

Reference Range: (32-37 g/dL)

• MCHC is a measure of average Hgb conc. in the RBC.

• Increased MCHC (>37) is associated with hereditary

spherocytosis and in newborns and infants.

• MCHC may be decreased (<30) in IDA, hemolytic

anemia, lead poisoning and thalassemia.
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 Reticulocytes count
Reference Range (0.5%-1.5% of RBC)
• Reticulocytes are immature RBCs formed in the BM.

• Helpful to identify the cause of anemia

• An increase in reticulocytes usually indicates an

increase in RBC production or decrease in RBC.
• Increase indicate anemia is due to blood loss and
decrease indicate anemia is due to bone marrow
disease
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Reticulocytosis occur Decreases in
Infectious causes
 Hemolytic anemia,
 Hemorrhage Alcoholism,
Renal disease (due to
 Sickle cell disease
decreased
 Response to therapy of erythropoietin)
Toxins
anemias 20 to iron,
Untreated IDA, and
vitamin B12, or folate
Drug-induced bone
deficiency marrow suppression

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 Patient Case
• Mrs Y is a 71-year-old woman who presents to the Tikur Anbesa
Specialized Hospital emergency department accompanied by her
daughter. On questioning, she states that she has been
experiencing fatigue, lethargy, and generalized weakness for 2–3
months.

• She also has been experiencing tingling and numbness in her feet
and hands, especially while knitting or manipulating small
objects. Pt denies weight loss, fever, night sweats, or vision
changes.
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 Lab Result

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Questions
• What lab abnormalities are present?
• Hgb, MCV, ret., Vit B12
• Is this patient anemic, if so what type of anemia?
• Yes, macrocytic anemia
• What is the most likely cause of anemia?
• Vit B12 deficiency
• What treatments and follow up will probably be
needed for this pt?
• Vit B12 supplementation and diet rich in Vit B12
• Hgb, Vit 12 conc, resolution of symptoms
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 Case
• C.U., a 58-year-old chronic alcoholic, was hospitalized after a
barroom brawl. A CBC was ordered, and the following RBC
indices were noted: MCV, 108 μm3; MCH, 38 pg; and MCHC,
34 g/dL. How should these indices be interpreted in C.U.?
Answer: Usually, the MCH and MCV are both increased and
the MCHC is normal in macrocytic anemias associated with
vitaminB12 or folic acid deficiency.
• The MCH is increased b/c the RBCs have increased in size;
however, the concentration of Hgb (MCHC) has not changed.
• This characteristic picture is illustrated in the alcoholic
patient, C.U., who is likely to have a dietary folic acid
deficiency

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 Erythrocyte Sedimentation Rate (ESR)
• Reference range:
 Male: 0 - 8mm/hr Female: 0-10mm/hr

• ESR or sed rate measures the rate at which RBCs in

anticoagulated blood settle to the bottom of a calibrated
tube.

• In normal blood, relatively little settling occurs because the

gravitational pull on the RBCs is almost balanced by the
upward force exerted by the plasma.
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• If plasma is extremely viscous or if cholesterol levels
are very high, the upward trend may virtually
neutralize the downward pull on the RBCs.
• In contrast, anything that encourages RBCs to
aggregate or stick together increases the rate of
settling.
– Collagen disorders, inflammations and infections

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 Increased Rate
Decreased Rate
• Pregnancy
• Collagen disorders (immune • Polycythemia vera
disorders of connective tissue) • Congestive heart failure
• Inflammatory disorders
• Sickle cell, Hgb C disease
• Infections
• Acute myocardial infarction • Degenerative joint dx
• Most malignancies • Cryoglobulinemia
• Drugs (oral contraceptives, dextran, • Drug toxicity (salicylates,
penicillamine, methyldopa, quinine derivatives,
procainamide, theophylline, vitamin adrenal corticosteroids)
A)
• Severe anemias
• Renal disease (nephritis)
• Hepatic cirrhosis
• Thyroid disorders
• 05/11/2022
Acute heavy metal poisoning 55
 Coagulation Tests

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• The most common laboratory tests to diagnose the
coagulation disorders and monitor the effectiveness
of patients receiving anticoagulation therapy are:

 Prothrombin time (PT)

 International normalization ratio (INR)

 Activated partial thromboplastin time (aPTT)

 Thrombin time

 Platelet count and bleeding time

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 Prothrombin Time (PT)

Normal: 10 to 13 seconds

• PT reflects the time required for fibrin strands

to appear after the addition of calcium and
tissue thromboplastin to the pt’s plasma.
Then, the time it takes for the blood to clot
is measured.
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• PT assesses the activity of the vitamin K–dependent
proteins (factors II, VII, IX, and X, and proteins C and
S) and common pathway proteins (factors V and X)
• Thus, PT provides evidence about the

 Current synthetic capacity of the liver

 Adequacy of vitamin K absorption, and

 Inhibition of clotting factor synthesis by warfarin

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• It is used to monitor warfarin therapy. But PT Varies with
thromboplastin and test method used, INR is a better monitoring
tool for warfarin.

• An increased PT may be seen with

 Anticoagulation therapy

 Liver disease

 Vitamin K deficiency and

 Clotting factor deficiencies

• The clinical presentation of prolonged PT is bleeding following

surgery, trauma, etc
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 International Normalized Ratio (INR)

• Because the PT may vary due to the thromboplastin used, the INR
is used to standardize the PT.

• The INR adjusts the PT ratio based on the sensitivity of the

thromboplastin used to perform the test.

• The INR may be calculated as follows:

INR = [(Patient PT)/(control PT)]ISI

ISI:- international sensitivity index rating assigned to a particular

thromboplastin.
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 Desired ranges for the INR depends on
indication for anticoagulation

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 • An INR below the desired range indicates
suboptimal anticoagulation and a need to
increase warfarin dosage.
• Conversely, an INR above the desired range
indicates a need to omit and/or reduce the
warfarin dosage.

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• Pts with elevated INRs and/or bleeding may require
the administration of vitamin K, fresh frozen plasma,
or clotting factors
• To appropriately interpret an INR value and decide on
the need for dosage adjustments, pts should be
questioned regarding dosage of warfarin, missed
doses, dietary intake, alcohol intake, and
concomitant medications.

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 Activated Partial Thromboplastin Time (aPTT)

– Reference Range (20 and 35 seconds) but varies per reagent

• aPTT reflects the time required for a fibrin clot to form

after a partial thromboplastin, calcium, & activating agent
are added to the pt’s plasma.

• aPTT is sensitive to changes in the intrinsic and common

coagulation pathways (factors II, V, VIII, IX, X, XI, and XII,
high-molecular weight kininogen, prekallikrein &
fibrinogen)
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 • It is used to monitor heparin therapy.

• The normal value above represents a control range for pts not

on anticoagulation therapy.

• Pts on heparin therapy will have an elevated aPTT.

• Much like the PT, the aPTT can vary depending on the reagent

(partial thromboplastin) used

• Therefore, a therapeutic range should be established for each

institution based on the partial thromboplastin used at that

laboratory
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• An aPTT below the desired therapeutic range
indicates the need to rebolus and/or increase
the heparin infusion rate
• An aPTT above the desired therapeutic
indicates the need to hold and/or reduce the
dose of heparin.
• Patients with clinically significant bleeding
may require reversal with protamine sulfate

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 BLEEDING TIME

– Reference Value: 3–10 minutes

• Bleeding time assesses platelet and capillary

function abnormalities.
• Bleeding time reflects the time to cessation of
bleeding following a standardized skin cut.
• The bleeding time is insensitive to mild platelet
defects, thus its use has decreased.
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• A prolonged bleeding time can be caused by:
 Incorrect performance of the test,
 Thrombocytopenia or platelet dysfunction,

 von Willebrand disease,

 Use of antiplatelet drugs (i.e. aspirin),
 Renal failure
 Fibrinogen disorders,

 Abnormal blood vessels, or

 Collagen disorders.
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 THROMBIN TIME
Reference value: 7-12 seconds

• The thrombin time measures the time required

for the formation and the appearance of the
fibrin clot after thrombin is added to plasma.
• It may be used to monitor the effect of systemic
fibrinolytic therapy and can be modified for
monitoring heparin therapy
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• Prolonged TT occurs in:
 Hypofibrinogenemia
 Therapy with heparin or heparin-like
anticoagulants
 DIC (Disseminated intravascular coagulation )
 Fibrinolysis
 Multiple myeloma
 Presence of large amounts of fibrin split products
(FSPs), as in DIC
 Uremia
 Severe liver diseases

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