POCT即时检验课件

1、Point-Of-Care Coagulation Testing: What is it? Why do we do it? Where are we going?,John A. Saavedra,International Sales Manager International Technidyne Corporation (ITC) Edison, New Jersey, USA,1,学习交流PPT,What is Point of Care Testing?,According to CAP (College of American Pathologists): testing pe

2、rformed at the bedside not in fixed dedicated space Performed by a large number of different non-laboratory healthcare personnel Utilizes portable devices or simple reagent kits different from those used in the primary laboratory.,2,学习交流PPT,Why Test Coagulation?,Monitor anticoagulation therapy Hepar

3、in and Warfarin are monitored Both have highly variable patient dose response. A therapeutic dose for patient A Thrombotic dose for patient B Hemorrhagic dose for patient C Determine patients hemostatic status,3,学习交流PPT,Why Point-Of-Care Testing?,Prompt Turn Around Time Improved Clinical Outcome Red

4、uced Length of Stay Standardization Improved, timely patient care,4,学习交流PPT,Benefit - Immediate Turn Around,When is Turn Around Important Operating Room and Cath Lab ICU/CCU Dose Adjustments Emergency Room,5,学习交流PPT,Immediate Turn Around,Fitch, et.al, J. Clin Monit 2 x 106 KIU pump prime; 0.5 x 106

5、KIU/hr infusion Half Hammersmith 1 x 106 KIU loading dose; 1 x 106 KIU pump prime; 0.25 x 106 KIU/hr infusion,18,学习交流PPT,ACT Monitoring with Aprotinin Treatment,Celite ACT Not recommended Still used with target times of 750 seconds Kaolin ACT Unaffected by moderate doses of aprotinin Used with targe

6、t times of 480 seconds ACT+ Unaffected by ALL doses of aprotinin Used with target times of 400 seconds,19,学习交流PPT,ACT Monitoring with Aprotinin Treatment,Data from clinical evaluation, on file, ITC,20,学习交流PPT,Other Point-Of-Care Coagulation Testing in the Operating Room,APTT some patients may be res

7、istant or sensitive to heparin They can represent 20 - 40% of patient population,22,学习交流PPT,Managing Heparin and Protamine Dosing,Heparin Resistance: Repeated exposure to heparin (from previous procedures) may reduce patients response to the drug Patient requires a higher dose of heparin in order to

8、 obtain the same anticoagulant effect,23,学习交流PPT,Managing Heparin and Protamine Dosing,Heparin Sensitivity: Patients response to heparin is greater than the average patient of the same height, weight and gender. Patient requires a lower heparin dose to obtain the same anticoagulant effect.,24,学习交流PP

9、T,Managing Heparin and Protamine Dosing,Benefits: Individualizes heparin dose for sensitive and resistant patients Reduces use of blood products needed for post-operative transfusions JOBES DR, et al. 1995. INCREASED ACCURACY AND PRECISION OF HEPARIN AND PROTAMINE DOSING REDUCES BLOOD LOSS AND TRANS

10、FUSION REQUIREMENTS IN PATIENTS UNDERGOING PRIMARY CARDIAC OPERATIONS. J THORAC CARDIOVASC SURG 110: 36-45,25,学习交流PPT,Managing Heparin and Protamine Dosing,Benefits: Reduces potential for protamine dose side effects Protamine reduced by average of 30% ZUCKER ML., et al. 1997. UTILITY OF IN VITRO HEP

11、ARIN AND PROTAMINE TITRATION FOR DOSING DURING CARDIOPULMONARY BYPASS SURGERY. J EXTRA-CORP TECH. 29: 176-180. Cost Savings JOBES D, et al. 1996. COST EFFECTIVE MANAGEMENT OF HEPARIN/PROTAMINE IN CP BYPASS: ANALYSIS BY TYPE OF SURGERY. ANESTHES 85: 3A,26,学习交流PPT,Other Point-Of-Care Coagulation Testi

12、ng in the Operating Room,Heparin neutralization verification Ensure complete removal of circulating heparin aPTT PDA-O - ACT based TT / HNTT - Thrombin Time based,27,学习交流PPT,Clinical Studies,Reduced Blood Loss/Transfusion Use of HRT and PRT (RxDx System) Jobes, D. et. al., 1995. J. Thorac.Cardiovasc

13、.Surg. Reduced Cost Resulting from POC Assays RxDx combined with TT / HNTT Jobes, D. et. al., 1996. Am Soc Anesth Mtg.,28,学习交流PPT,Clinical Studies,Reduced Complication Rates TT /HNTT Re-Exploration for Bleeding Reduced from 2.5% to 1.1% Re-Exploration for Coagulopathy Reduced from 1.0% to 0.0% Jobes

14、, et.al. 1997, NACB Presentation, Phila, PA.,29,学习交流PPT,Point-Of-Care Coagulation Testing,Clinical Applications Operating Room Cardiac Surgery Interventional Cardiology and Radiology Critical Care Satellite Sites Dialysis ECMO Emergency Room Anticoagulation Clinic,30,学习交流PPT,Critical Care,ACT Determ

15、ine when to pull the femoral sheath High ACT values indicate the presence of heparin. Premature sheath pull can lead to bleeding complications. Delayed removal can increase time in both the CCU and hospital Target ACT set at each site Varies from 150 sec to 250 second Monitor heparin therapy Target

16、times determined by each facility Targets usually set as 1.5-2x baseline ACT values (180 - 240 seconds).,31,学习交流PPT,Critical Care,APTT Laboratory or Point of Care High APTT values indicate the presence of heparin or underlying coagulopathy Determine when to pull the femoral sheath Target times deter

17、mined by each facility. Monitor heparin therapy Target times determined by each facility Targets are set as 1.5-2x baseline 50-80 seconds Monitor during heparin / coumadin cross-over,32,学习交流PPT,Heparin versus Warfarin,33,学习交流PPT,What Do the Test Results Mean?,PT Laboratory or Point of Care Monitor w

18、arfarin therapy Monitor heparin/warfarin crossover Target times are set by International Normalized Ratio (INR) ISI = international Sensitivity Index INR target ranges are specified by patient populations prophylactic therapy for DVT: INR= 2.0 - 3.0 artificial heart valve: INR=3.0 - 4.0,34,学习交流PPT,W

19、ill Results Match the Lab?,Probably not but they WILL correlate,35,学习交流PPT,Why?,Point of Care Whole Blood No Added Anticoagulant No Dilution No Preanalytical Delay,Standard Laboratory Platelet Poor Plasma Sodium Citrate Anticoagulant 1:9 Dilution Variable Preanalytical Delay,36,学习交流PPT,Correlations

20、with different systems,37,学习交流PPT,Signature INR vs Lab,38,学习交流PPT,Point-Of-Care Coagulation Testing,Clinical Applications Operating Room Cardiac Surgery Interventional Cardiology and Radiology Critical Care Satellite Sites Dialysis ECMO Emergency Room Anticoagulation Clinic,39,学习交流PPT,Dialysis / ECM

21、O,ACT used to monitor heparin Use P214 glass activated ACT tube or ACT-LR cuvette Targets generally 180 - 220 seconds Better Control of Anticoagulation Leads to Increased Dialyzer Reuse Potential for Long Term Cost Savings No Compromise in Dialysis Efficacy (Kt/V) Ouseph, R. et.al. Am J Kidney Dis 3

22、5:89-94; 2000,40,学习交流PPT,Emergency Room,ACT; aPTT; PT; Fibrinogen Immediate Identification of Coagulopathies Optimization of Critical Decision Pathways ACT Allows Early Detection of Traumatic Coagulopathy Allows Early Treatment Decisions Aids Damage Control Decisions Aucar, J. et.al. 1998 SW Surgeon

23、s Congress Optimize Staffing During Off Hours,41,学习交流PPT,Anticoagulation Clinics,Results Available While Patient is Present Improved Anticoagulation Management Improved Standard of Care Staff Efficiency Immediate Retesting (if needed) Fingerstick Sampling Same System for Clinic and Home Bound Patients Standardized ISI (Test System Specific),42