Chapter 23.

Preoperative Coagulation
Assessment
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Assessment of Coagulation and Coagulation Tests
 Automated counting cannot detect the presence of small or
extremely large platelets
 Manual smear can exclude the presence of
Platelet count
pseudothrombocytopenia due to in vitro platelet
agglutination

 Evaluate platelet–vascular endothelium interaction

 Prolonged bleeding time may occur in thrombocytopenia
(<50,000), qualitative platelet abnormalities (e.g., uremia),
von Willebrand disease (vWD), and severe fibrinogen
Bleeding time
deficiency
 Does not predict surgical bleeding and is of limited
usefulness in clinical bleeding

 Measures the efficiency of the fibrin production through

the extrinsic pathway and the final common pathway:
 Tissue factor, factor VII (extrinsic pathway), and factors
X, V, prothrombin (factor II), and fibrinogen
Prothrombin time (PT)
 Factors VII, X, and prothrombin are dependent on vitamin
K and affected by coumadin; therefore, PT is used to
monitor anticoagulation with coumadin

 Compensates for differences in PT reagents:

International normalized
 INR = patient PT/control PT
ratio (INR)

 Measures the intrinsic (factors XII, XI, IX, VIII) and

Activated partial common pathway (factors II, V, X, and fibrinogen)
thromboplastin time  Used to monitor heparin effect and to evaluate deficiencies
(aPTT) of all coagulation factors except factors VII and XIII

Thrombin time (TT)  Measures the time it takes for a clot to form in the plasma
of a blood sample to which an excess of thrombin has been
added
 If a patient is receiving heparin, a substance derived from
snake venom called reptilase (not inhibited by heparin) is
used instead of thrombin
 Normal TT: 10–15 s or within 5 s of the control. Normal
reptilase time: between 15 and 20 s
  TT can be prolonged by heparin, fibrin degradation
products, factor XIII deficiency, and fibrinogen
deficiency/abnormality

 An activating agent such as Celite or kaolin is added to a

blood sample and the time to clot formation is measured
Activated clotting time
 Used to confirm and monitor heparin effect as a point-of-
(ACT)
care test during cardiac or vascular surgery

 Thromboelastography measures clinical clot formation and

lysis not specific to coagulation pathways
 TEG reflects clinically significant hemostasis and can
Thromboelastography
guide transfusion and factor therapy
 Coagulation is activated by ...