POCT即时检验

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