POCT即时检验(基础教学)课件.ppt

1、John A.SaavedraInternational Sales ManagerInternational Technidyne Corporation(ITC)Edison,New Jersey,USA1教学资料What is Point of Care Testing?l According to CAP(College of American Pathologists):testing performed at the bedsidenot in fixed dedicated spacel Performed by a large number of different non-l

2、aboratory healthcare personnell Utilizes portable devices or simple reagent kits different from those used in the primary laboratory.2教学资料lMonitor anticoagulation therapyHeparin and Warfarin are monitoredlBoth have highly variable patient dose response.lA therapeutic dose for patient AThrombotic dos

3、e for patient BHemorrhagic dose for patient ClDetermine patients hemostatic status3教学资料lPrompt Turn Around TimelImproved Clinical OutcomelReduced Length of StaylStandardizationlImproved,timely patient care4教学资料lWhen is Turn Around ImportantOperating Room and Cath LabICU/CCU Dose AdjustmentsEmergency

4、 Room5教学资料Lab (min)MedianCPB(N=40)90.0PVS(N=45)90.0Mean78.574.0Minimum38.021.0POC(min)MedianAll Groups2.23Minimum0.33Maximum6.97Fitch,et.al,J.Clin Monit&Comput.1999.15:197-2046教学资料lPost Surgical PatientsReduced blood lossReduced transfusion requirementslHeparin DripResults Obtained Prior to Next Sch

5、eduled Test Fewer,More Rapid Dosage AdjustmentsReduction in Length of StaylOverall cost reduction7教学资料lHEMOCHRON ResponselHEMOCHRON Jr.II/SignaturelProTimelMedtronic HMS/HemoTec ACT IIlRoche CoaguChek/CoaguChek ProlBayer RapidPointli-STATlOthers8教学资料lTest MenuACT-multiple activatorsDosing Assays for

6、 Open Heart SurgerylHeparin and ProtamineAPTT-fresh or citrated bloodPT-fresh or citrated bloodFibrinogenTT-thrombin time9教学资料uClinical Applications Operating RoomlCardiac SurgerylInterventional Cardiology and RadiologyCritical Care Satellite SiteslDialysislECMOlEmergency RoomlAnticoagulation Clinic

7、10教学资料Maintain BalanceBleeding ThrombosisHeparinRapid Anticoagulant EffectIndividual sensitivities vary significantlyPotency differencesSource:Bovine or PorcineLot to Lot variabilityRapidly Reversible with Protamine11教学资料0100200300400500600700012345Heparin(units/ml)Clotting Time(sec)C-ACTK-ACTACT+P2

8、14ACT-LRCCUDialysisCATHPTCACPB12教学资料lBenefitsIndustry Standard Since 1970 Hemochron pioneered ACT testing in 1969Recommended as primary method in AmSECT guidelines(perfusion)Easy to runInexpensive13教学资料lDisadvantagesEach system yields somewhat different numbersHigh sensitivity to hypothermia and hem

9、odilution(with exceptions)Little correlation to heparin level in pediatric patients14教学资料lData from clinical evaluation,on file,ITC01002003004005006007008009001000BaselinePostBolusPostBolus2OnPumpOnPump2OnPump3PostProt.Clotting TimeKaolin ACTCelite ACTACT+15教学资料Pediatric Cardiac Surgery0100200300400

10、500600700baselinepost-boluson pumprewarmpost-CPBtime during bypassClotting time(sec)FTCA510ACT+lData from clinical evaluation,on file,ITC16教学资料lAmicar or Transexamic AcidNo effect on standard celite ACTContinued debate on efficacylMultiple reports of reduction in post-operative blood loss and reduce

11、d transfusion requirements17教学资料lAprotininSignificant elevation of celite ACTTwo dosing regimenslFull Hammersmith2 x 106 KIU loading dose;2 x 106 KIU pump prime;0.5 x 106 KIU/hr infusion lHalf Hammersmith1 x 106 KIU loading dose;1 x 106 KIU pump prime;0.25 x 106 KIU/hr infusion18教学资料lCelite ACTNot r

12、ecommendedStill used with target times of 750 secondslKaolin ACTUnaffected by moderate doses of aprotininUsed with target times of 480 secondslACT+Unaffected by ALL doses of aprotininUsed with target times of 400 seconds19教学资料020040060080010001200BaselinePostBolusPostBolus2OnPumpOnPump2OnPump3PostPr

13、ot.Clotting Time .Kaolin ACTCelite ACTACT+Data from clinical evaluation,on file,ITC20教学资料lAPTT&PTPre-and post-procedural screeninglFibrinogenPre-and post-procedural screeninglDosing AssaysIndividualized heparin and protamine dose lHEMOCHRON HRT/PRTlHepcon HMS21教学资料lWhy is management important?Tradit

14、ional dosing regimens recommend fixed drug doses by body weight.For most patients,this regimen provides adequate anticoagulation.lRegimen does not account for patients whose response to heparin is different than the average patient.Patients differ in their response to heparin;some patients may be re

15、sistant or sensitive to heparinlThey can represent 20-40%of patient population22教学资料lHeparin Resistance:Repeated exposure to heparin(from previous procedures)may reduce patients response to the druglPatient requires a higher dose of heparin in order to obtain the same anticoagulant effect23教学资料lHepa

16、rin Sensitivity:Patients response to heparin is greater than the average patient of the same height,weight and gender.lPatient requires a lower heparin dose to obtain the same anticoagulant effect.24教学资料lBenefits:Individualizes heparin dose for sensitive and resistant patientsReduces use of blood pr

17、oducts needed for post-operative transfusionslJOBES DR,et al.1995.INCREASED ACCURACY AND PRECISION OF HEPARIN AND PROTAMINE DOSING REDUCES BLOOD LOSS AND TRANSFUSION REQUIREMENTS IN PATIENTS UNDERGOING PRIMARY CARDIAC OPERATIONS.J THORAC CARDIOVASC SURG 110:36-45 25教学资料lBenefits:Reduces potential fo

18、r protamine dose side effectslProtamine reduced by average of 30%ZUCKER ML.,et al.1997.UTILITY OF IN VITRO HEPARIN 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 C

19、P BYPASS:ANALYSIS BY TYPE OF SURGERY.ANESTHES 85:3A26教学资料lHeparin neutralization verificationEnsure complete removal of circulating heparinlaPTTlPDA-O-ACT basedlTT/HNTT-Thrombin Time based27教学资料nReduced Blood Loss/TransfusionUse of HRT and PRT(RxDx System)lJobes,D.et.al.,1995.J.Thorac.Cardiovasc.Sur

20、g.lReduced CostResulting from POC AssaysRxDx combined with TT/HNTTlJobes,D.et.al.,1996.Am Soc Anesth Mtg.28教学资料nReduced Complication RatesTT/HNTTRe-Exploration for Bleeding Reduced from 2.5%to 1.1%Re-Exploration for Coagulopathy Reduced from 1.0%to 0.0%Jobes,et.al.1997,NACB Presentation,Phila,PA.29教

21、学资料uClinical Applications Operating RoomlCardiac SurgerylInterventional Cardiology and RadiologyCritical Care Satellite SiteslDialysislECMOlEmergency RoomlAnticoagulation Clinic30教学资料lACTDetermine when to pull the femoral sheath lHigh ACT values indicate the presence of heparin.Premature sheath pull

22、 can lead to bleeding complications.Delayed removal can increase time in both the CCU and hospitallTarget ACT set at each siteVaries from 150 sec to 250 secondMonitor heparin therapylTarget times determined by each facilityTargets usually set as 1.5-2x baseline ACT values(180-240 seconds).31教学资料lAPT

23、TLaboratory or Point of CareHigh APTT values indicate the presence of heparin or underlying coagulopathyDetermine when to pull the femoral sheath lTarget times determined by each facility.Monitor heparin therapylTarget times determined by each facilityTargets are set as 1.5-2x baseline50-80 secondsl

24、Monitor during heparin/coumadin cross-over32教学资料DrugActionMechan-ismMoni-toringEffectiveHeparinDirectInhibition ofThrombinATIIIcofactorAPTTACTImmediateWarfarinDecreasesProductionof factorsVitamin KPTDelay3-5 days33教学资料lPTLaboratory or Point of Care Monitor warfarin therapyMonitor heparin/warfarin cr

25、ossoverlTarget times are set by International Normalized Ratio(INR)ISI=international Sensitivity IndexlINR target ranges are specified by patient populationsprophylactic therapy for DVT:INR=2.0-3.0artificial heart valve:INR=3.0-4.0ISImeannormalpatientPTPTINR34教学资料Probably notbut they WILL correlate3

26、5教学资料lPoint of CareWhole BloodNo Added AnticoagulantNo DilutionNo Preanalytical DelaylStandard LaboratoryPlatelet Poor PlasmaSodium Citrate Anticoagulant1:9 DilutionVariable Preanalytical Delay36教学资料Dade Actin/MLAy=0.72x+11.5R=0.883203040506070203040506070labSignatureIL aPTT SP/ACL#2y=0.59x+16.0R=0.

27、96110.030.050.070.090.0110.0130.0150.01030507090110130150labSignatureIL aPTT C/ACL#3y=0.44x+22.2R=0.953310.030.050.070.090.0110.0130.0150.01030507090110130150labSignatureOrganon Technika/MDAy=1.02x+4.1R=0.942203040506070203040506070labSignature37教学资料y=0.578x+0.7994R2=0.9238R=.9611012345678024681012H

28、ospital INRSignature INR38教学资料uClinical Applications Operating RoomlCardiac SurgerylInterventional Cardiology and RadiologyCritical Care Satellite SiteslDialysislECMOlEmergency RoomlAnticoagulation Clinic39教学资料lACT used to monitor heparinUse P214 glass activated ACT tube or ACT-LR cuvetteTargets gen

29、erally 180-220 secondslBetter Control of Anticoagulation Leads to Increased Dialyzer ReusePotential for Long Term Cost SavingsNo Compromise in Dialysis Efficacy(Kt/V)lOuseph,R.et.al.Am J Kidney Dis 35:89-94;200040教学资料lACT;aPTT;PT;FibrinogenlImmediate Identification of CoagulopathiesOptimization of C

30、ritical Decision PathwayslACT Allows Early Detection of Traumatic CoagulopathyAllows Early Treatment DecisionsAids Damage Control DecisionslAucar,J.et.al.1998 SW Surgeons CongresslOptimize Staffing During Off Hours41教学资料lResults Available While Patient is PresentImproved Anticoagulation ManagementIm

31、proved Standard of CareStaff EfficiencylImmediate Retesting(if needed)Fingerstick SamplinglSame System for Clinic and Home Bound PatientsStandardized ISI(Test System Specific)42教学资料lPotential for Self-TestingHigh Risk PatientsPatients Who Travel FrequentlyHome-BoundPatients in Rural Areas Far from C

32、liniclImproved Outcomes Through More Frequent TestinglAnsell,J.1997 ISTH Mtg.lBecker,D.et.al.1997 Am Coll Cardiol Mtg.43教学资料lPoint of Care Coagulation Testing Has Measurable Clinical BenefitsPatient OutcomeCost Reduction44教学资料lImproved,User-Friendly SystemsMicrosampleMinimal training requiredSimple Quality ControllElectronic controlslUnitized controlSimplify record keepinglData storage in instrumentlTransfer of data to computer or Hospital Information System/Laboratory Information System45教学资料46教学资料