POCT即时检验PPT课件

精选,1,Point-Of-CareCoagulationTesting:Whatisit?Whydowedoit?Wherearewegoing?,JohnA.Saavedra,InternationalSalesManagerInternationalTechnidyneCorporation(ITC)Edison,NewJersey,USA,精选,2,WhatisPointofCareTesting?,AccordingtoCAP(CollegeofAmericanPathologists):testingperformedatthebedsidenotinfixeddedicatedspacePerformedbyalargenumberofdifferentnon-laboratoryhealthcarepersonnelUtilizesportabledevicesorsimplereagentkitsdifferentfromthoseusedintheprimarylaboratory.,精选,3,WhyTestCoagulation?,MonitoranticoagulationtherapyHeparinandWarfarinaremonitoredBothhavehighlyvariablepatientdoseresponse.AtherapeuticdoseforpatientAThromboticdoseforpatientBHemorrhagicdoseforpatientCDeterminepatientshemostaticstatus,精选,4,WhyPoint-Of-CareTesting?,PromptTurnAroundTimeImprovedClinicalOutcomeReducedLengthofStayStandardizationImproved,timelypatientcare,精选,5,Benefit-ImmediateTurnAround,WhenisTurnAroundImportantOperatingRoomandCathLabICU/CCUDoseAdjustmentsEmergencyRoom,精选,6,ImmediateTurnAround,Fitch,et.al,J.ClinMonit2x106KIUpumpprime;0.5x106KIU/hrinfusionHalfHammersmith1x106KIUloadingdose;1x106KIUpumpprime;0.25x106KIU/hrinfusion,精选,19,ACTMonitoringwithAprotininTreatment,CeliteACTNotrecommendedStillusedwithtargettimesof750secondsKaolinACTUnaffectedbymoderatedosesofaprotininUsedwithtargettimesof480secondsACT+UnaffectedbyALLdosesofaprotininUsedwithtargettimesof400seconds,精选,20,ACTMonitoringwithAprotininTreatment,Datafromclinicalevaluation,onfile,ITC,精选,21,OtherPoint-Of-CareCoagulationTestingintheOperatingRoom,APTTsomepatientsmayberesistantorsensitivetoheparinTheycanrepresent20-40%ofpatientpopulation,精选,23,ManagingHeparinandProtamineDosing,HeparinResistance:Repeatedexposuretoheparin(frompreviousprocedures)mayreducepatientsresponsetothedrugPatientrequiresahigherdoseofheparininordertoobtainthesameanticoagulanteffect,精选,24,ManagingHeparinandProtamineDosing,HeparinSensitivity:Patientsresponsetoheparinisgreaterthantheaveragepatientofthesameheight,weightandgender.Patientrequiresalowerheparindosetoobtainthesameanticoagulanteffect.,精选,25,ManagingHeparinandProtamineDosing,Benefits:IndividualizesheparindoseforsensitiveandresistantpatientsReducesuseofbloodproductsneededforpost-operativetransfusionsJOBESDR,etal.1995.INCREASEDACCURACYANDPRECISIONOFHEPARINANDPROTAMINEDOSINGREDUCESBLOODLOSSANDTRANSFUSIONREQUIREMENTSINPATIENTSUNDERGOINGPRIMARYCARDIACOPERATIONS.JTHORACCARDIOVASCSURG110:36-45,精选,26,ManagingHeparinandProtamineDosing,Benefits:ReducespotentialforprotaminedosesideeffectsProtaminereducedbyaverageof30%ZUCKERML.,etal.1997.UTILITYOFINVITROHEPARINANDPROTAMINETITRATIONFORDOSINGDURINGCARDIOPULMONARYBYPASSSURGERY.JEXTRA-CORPTECH.29:176-180.CostSavingsJOBESD,etal.1996.COSTEFFECTIVEMANAGEMENTOFHEPARIN/PROTAMINEINCPBYPASS:ANALYSISBYTYPEOFSURGERY.ANESTHES85:3A,精选,27,OtherPoint-Of-CareCoagulationTestingintheOperatingRoom,HeparinneutralizationverificationEnsurecompleteremovalofcirculatingheparinaPTTPDA-O-ACTbasedTT/HNTT-ThrombinTimebased,精选,28,ClinicalStudies,ReducedBloodLoss/TransfusionUseofHRTandPRT(RxDxSystem)Jobes,D.et.al.,1995.J.Thorac.Cardiovasc.Surg.ReducedCostResultingfromPOCAssaysRxDxcombinedwithTT/HNTTJobes,D.et.al.,1996.AmSocAnesthMtg.,精选,29,ClinicalStudies,ReducedComplicationRatesTT/HNTTRe-ExplorationforBleedingReducedfrom2.5%to1.1%Re-ExplorationforCoagulopathyReducedfrom1.0%to0.0%Jobes,et.al.1997,NACBPresentation,Phila,PA.,精选,30,Point-Of-CareCoagulationTesting,ClinicalApplicationsOperatingRoomCardiacSurgeryInterventionalCardiologyandRadiologyCriticalCareSatelliteSitesDialysisECMOEmergencyRoomAnticoagulationClinic,精选,31,CriticalCare,ACTDeterminewhentopullthefemoralsheathHighACTvaluesindicatethepresenceofheparin.Prematuresheathpullcanleadtobleedingcomplications.DelayedremovalcanincreasetimeinboththeCCUandhospitalTargetACTsetateachsiteVariesfrom150secto250secondMonitorheparintherapyTargettimesdeterminedbyeachfacilityTargetsusuallysetas1.5-2xbaselineACTvalues(180-240seconds).,精选,32,CriticalCare,APTTLaboratoryorPointofCareHighAPTTvaluesindicatethepresenceofheparinorunderlyingcoagulopathyDeterminewhentopullthefemoralsheathTargettimesdeterminedbyeachfacility.MonitorheparintherapyTargettimesdeterminedbyeachfacilityTargetsaresetas1.5-2xbaseline50-80secondsMonitorduringheparin/coumadincross-over,精选,33,HeparinversusWarfarin,精选,34,WhatDotheTestResultsMean?,PTLaboratoryorPointofCareMonitorwarfarintherapyMonitorheparin/warfarincrossoverTargettimesaresetbyInternationalNormalizedRatio(INR)ISI=internationalSensitivityIndexINRtargetrangesarespecifiedbypatientpopulationsprophylactictherapyforDVT:INR=2.0-3.0artificialheartvalve:INR=3.0-4.0,精选,35,WillResultsMatchtheLab?,ProbablynotbuttheyWILLcorrelate,精选,36,Why?,PointofCareWholeBloodNoAddedAnticoagulantNoDilutionNoPreanalyticalDelay,StandardLaboratoryPlateletPoorPlasmaSodiumCitrateAnticoagulant1:9DilutionVariablePreanalyticalDelay,精选,37,Correlationswithdifferentsystems,精选,38,SignatureINRvsLab,精选,39,Point-Of-CareCoagulationTesting,ClinicalApplicationsOperatingRoomCardiacSurgeryInterventionalCardiologyandRadiologyCriticalCareSatelliteSitesDialysisECMOEmergencyRoomAnticoagulationClinic,精选,40,Dialysis/ECMO,ACTusedtomonitorheparinUseP214glassactivatedACTtubeorACT-LRcuvetteTargetsgenerally180-220secondsBetterControlofAnticoagulationLeadstoIncreasedDialyzerReusePotentialforLongTermCostSavingsNoCompromiseinDialysisEfficacy(Kt/V)Ouseph,R.et.al.AmJKidneyDis35:89-94;2000,精选,41,EmergencyRoom,ACT;aPTT;PT;FibrinogenImmediateIdentificationofCoagulopathiesOptimizationofCriticalDecisionPathwaysACTAllowsEarlyDetectionofTraumaticCoagulopathyAllowsEarlyTreatmentDecisionsAidsDamageControlDecisionsAucar,J.et.al.1998SWSurgeonsCongressOptimizeStaffingDuringOffHours,精选,42,AnticoagulationClinics,ResultsAvailableWhilePatientisPresentImprovedAnticoagulationManagementImprovedStandardofCareStaffEfficiencyImmediateRetesting(ifneeded)FingerstickSamplingSameSystemforClinicandHomeBoundPatientsStandardizedISI(TestSystemSpecific