Angeles University Foundation

College of Allied Medical Professions

BLEEDING
TIME
(Written Report)

Submitted By:
Group 10
BSMT4

Burnett, John Brandon

Parker, Maria Janina
Salvador, Maricris
Sanchez, Kimberly
Villafuerte, Karla

Submitted To:
Crizelda T. Liwanag
 May 24, 2011

Background

Functional platelet evaluation was first available with the introduction of the bleeding time.

Developed by Dr. William W. Duke in 1910. The test has poor reproducibility and unreliable test
results due to variability of earlobe thickness and variability of puncture depth. Outdated, rarely
performed procedure - replaced by Ivy Bleeding Time

Duke Bleeding Time

The duke bleeding time is performed by a skin puncture on patient's earlobe with a lancet. The bleeding
time is determined by using the time it takes for the wound to stop bleeding. The technician uses filter
paper to blot the area and check for a blood clot.

Modified Ivy Bleeding Time

1941 - Ivy (et al) introduced a standardized Ivy bleeding time test. The Ivy bleeding time uses the
forearm as the site. A blood pressure cuff is inflated to 40 mm Hg on the upper arm to control
capillary tone which improves the sensitivity and reproducibility of test. The Ivy Bleeding time is a
highly sensitive and has good reproducibility.

Sensitivity: Ability of a test to detect borderline abnormalities. The more sensitive a test is, the
more likely it is to detect small deviations from normal.

Reproducibility: Refers to the reproducibility of test results. If a test has high reproducibility, 2
persons performing the same procedure under identical circumstances will arrive at identical results.

1969 - Mielke modified the Ivy Bleeding Time. The introduction of a standardized scalpel blade to
produce an incision of standard length and depth.

Advantages of template:
• "Surgical" incision more closely approximated patient's
• hemostatic response to surgery
• Large surface area of template (longer incision) minimized
• skin displacement
• Depth of incision was controlled

1978 - Commercially available Bleeding Time Device were individually sterilized and packaged.

Bleeding Time Devices

• Incision instruments which are housed in plastic units
• Used only once & then discarded
• Several automated bleeding time devices are currently on the market
• (Simplate, Surgicutt, et al)
 • Normal values will depend on the bleeding time instrument used

Bleeding Time

− Qualitative platelet evaluation

− It is the time that takes for a standard wound to stop bleeding.
− Time between the first appearance of blood and the stopping of blood flow.
− Bleeding time is a crude test of hemostasis (the arrest or stopping of bleeding). It indicates how
well platelets interact with blood vessel walls to form blood clots.

Bleeding time is used most often to detect qualitative defects of platelets. The test helps identify people
who have defects in their platelet function. This is the ability of blood to clot following a wound or
trauma. Normally, platelets interact with the walls of blood vessels to cause a blood clot. There are
many factors in the clotting mechanism, and they are initiated by platelets. The bleeding time test is
usually used on patients who have a history of prolonged bleeding after cuts, or who have a family
history of bleeding disorders. Also, the bleeding time test is sometimes performed as a preoperative test
to determine a patient's likely bleeding response during and after surgery. However, in patients with no
history of bleeding problems, or who are not taking anti-inflammatory drugs, the bleeding time test is
not usually necessary.

Principle

A skin puncture is performed & the technician measures the time it takes for the wound to stop
bleeding.

Purpose
• To assess the patient's platelet function & blood vessel integrity which initiate the primary blood
clotting mechanism.
• Check for low levels of blood clotting factors. The lack of some clotting factors can cause
bleeding disorders such as hemophilia, which is passed in families (inherited).
• Check for a low level of vitamin K. Vitamin K is needed to make prothrombin and other
clotting factors.
• Check how well the liver is working. Prothrombin levels are checked along with other liver
tests, such as aspartate aminotransferase and alanine aminotransferase.
• Check to see if the body is using up its clotting factors so quickly that the blood cannot clot and
bleeding does not stop. This may mean the person has disseminated intravascular coagulation
(DIC).

Clinical Significance: Used as a presurgical screening tool which detects the following disorders of
primary hemostasis:
• vonWillebrand's disease
• Congenital or Acquired platelet defects
• Vascular disorders
The bleeding time is influenced by various physiological factors such as: Platelet count, Platelet
function, Circulating vonWillebrand's factor, and Vascular tone. Aspirin and Aspirin containing
compounds may affect the bleeding time.
- Aspirin affects platelet functioning Ψ increases bleeding time test
- Aspirin affects platelet functioning for as long as 7-10 days

Quality Assurance / Precautions

• Blood pressure cuffs must be appropriately applied to the patient's arm. The gauge should be
maintained at 40 mm Hg throughout the procedure.

• To ensure accurate, reproducible results, the length, depth, & direction of the bleeding time
device must be standardized.

Incision lengths
1. The shorter the length of the device, the shorter the bleeding time results.
2. The choice of bleeding time instrument determines the length of the incision
3. The most common length is 5 mm.

Incision depth
1. Critical to accuracy of the bleeding time results
2. Incision should be superficial so only capillaries & small blood vessels are involved
3. A depth of 1 mm is recommended (All commercially prepared bleeding time devices are gauged to
make incisions 1 mm deep)
4. A phlebotomists should exercise care not to exert pressure on the bleeding time device while making
the incision. With even slight pressure, significant skin indentation can occur which would result in an
incision > 1 mm deep

Incision direction
1. Incisions may be made either horizontally or vertically to antecubital crease as long as everyone in
the facility position the device in the same direction

Horizontal incisions
a. More sensitive to effects of aspirin &/or borderline abnormalities in the primary hemostatic
mechanism consistent with direction of skin lines on the forearm is less noticeable scarring

• Cleansing of site prior to incision must be gentle. Vigorous cleaning may induce hyperemia
(excessive accumulation of blood at the puncture site).

• Do not touch the incision with the filter paper. If the incision is disturbed during wicking
process, adhering platelets may become dislodged resulting in a falsely prolonged bleeding
time. A diminished blood flow followed by sudden resurgence in bleeding may indicate such an
occurrence.

• Activity after test - If the patient has a bleeding tendency, such as hemophilia, keep a pressure
bandage over the incision for 24 to 48 hours to prevent further bleeding, or else if no bleeding
 tendency, a piece of gauze with a bandage should be sufficient. Resume taking any medications
that were withheld before the test. Bleeding time depends on the elasticity of the blood-vessel
wall and on the number and functional capacity of platelets.

• Patients should be questioned about what medications they may be taking. Some medications
will adversely affect the results of the bleeding time test. These medications include
anticoagulants, diuretics, anticancer drugs, sulfonamides, thiazide, aspirin and aspirin-
containing preparations, and nonsteroidal anti-inflammatory drugs.

Procedures (Ivy Method)

1. Place a blood pressure cuff on the patient's arm just above the elbow. Maintain at a pressure of
40mm Hg during the entire procedure.
2. Clean an area on the volar surface of the forearm with a cotton with alcohol and allow to dry.
3. Choose an area approximately three finger widths below the bend in the elbow. Hold the skin
tightly by grasping the underside of the arm firmly. Make two skin puncture, 3 mm deep,
avoiding any subcutaneous veins. Start the stopwatch as soon as the blood starts to ooze out of
the wound.
4. Blot the blood from each puncture site with separate sheets of filter paper every 30 seconds. It
should be avoided not to touch the wound with the filter paper.
5. When bleeding ceases, stop the watch and release the blood pressure cuff.
6. Record the bleeding times of the two puncture sites and report the average of the two results.

Interpretation of Results

Normal bleeding time using Ivy's Method is less than 5 minutes. Some extend to 8 minutes.

A bleeding time that is longer than normal is an abnormal result. The test should be stopped if the
patient hasn't stopped bleeding by 20-30 minutes. Bleeding time is longer when the normal function of
platelets is impaired, or there are a lower-than-normal number of platelets in the blood.

A longer-than-normal bleeding time can indicate that one of several defects in hemostasis is present,
including severe thrombocytopenia, platelet dysfunction, vascular defects, Von Willebrand's disease, or
other abnormalities.

Questions for Research

1. Identify 2 important uses of Bleeding Time

• Bleeding time is a medical test done on someone to assess their platelet function. A bleeding
time test can be used to check for bleeding problems.

• BT is also used to check whether medicine to prevent blood clots is working. If the platelets are
reduced in number, or if they are abnormal from disease or medicine (aspirin, for example), the
bleeding time will be prolonged.

2. Identify at least 3 conditions/diseases associated with a prolonged BT.

 Conditions/diseases associated with a prolonged Bleeding Time:
• Disseminated intravascular coagulation
• Drug therapy
• Bernard-Soulier syndrome (evidenced by a rare hereditary condition in which platelet
glycoprotein GP1b is deficient and platelet aggregation is decreased)
• Fibrinogen disorders (fibrinogen helps platelets link together)
• Glanzmann's thrombasthenia (evidenced by a rare hereditary condition in which platelet
glycoprotein IIb/IIIa is deficient and platelet aggregation is decreased)
• Hereditary telangiectasia (evidenced by fragile blood vessels that do not permit adequate
constriction to stop bleeding)
• Liver disease (related to decreased production of coagulation proteins that affect
bleeding time)
• Some myeloproliferative disorders (evidenced by disorders of decreased platelet
production)
• Renal disease (related to abnormal platelet function)
• Thrombocytopenia (evidenced by insufficient platelets to stop bleeding)
• von Willebrand's disease (evidenced by deficiency of von Willebrand factor, necessary
for normal platelet adhesion)

3. Identify 3 kinds of drugs that can prolong BT.

Before administering the test, patients should be questioned about what medications they may be
taking. Some medications will adversely affect the results of the bleeding time test. These medications
include anticoagulants, diuretics, anticancer drugs, sulfonamides, thiazide, aspirin and aspirin-
containing preparations, and nonsteroidal anti-inflammatory drugs. The test may also be affected by
anemia (a deficiency in red blood cells). Since the taking of aspirin or related drugs are the most
common cause of prolonged bleeding time, no aspirin should be taken two weeks prior to the test.

a. Dextran

It is used medicinally as an antithrombotic(anti-platelet), to reduce blood viscosity, and as a

volume expander in anemia.

The antithrombotic effect of dextran is mediated through its binding of erythrocytes, platelets,
and vascular endothelium, increasing their electronegativity and thus reducing erythrocyte
aggregation and platelet adhesiveness. Dextrans also reduce factor VIII-Ag Von Willebrand
factor, thereby decreasing platelet function. Clots formed after administration of dextrans are
more easily lysed due to an altered thrombus structure (more evenly distributed platelets with
coarser fibrin). By inhibiting α-2 antiplasmin, dextran serves as a plasminogen activator and
therefore possesses thrombolytic features.

b. Dipyridamole

Acts as vasodilator and antiplatelet agent. It inhibits adenosine uptake and cyclic GMP
phosphodiesterase activity, this decreases platelet aggregability. Dipyridamole alone has little
antiplatelet effect, it is currently used in combination with aspirin or warfarin in the prophylaxis
 of thromboembolic disorders. It is also used in stress testing for myocardial perfusion imaging.

c. Aspirin

Inhibits platelet cyclooxygenase, a key enzyme in thromboxane A2 (TXA2) generation.

Thromboxane A2 triggers reactions that lead to platelet activation and aggregation, aspirin acts
as a potent antiplatelet agent by inhibiting generation of this mediator. These effects last for the
life of the anucleate platelet, approximately 7 to 10 days.

4. Using your own words or with use of a flowchart, describe briefly the process or mechanism
of action involved in the primary hemostasis.

Primary Hemostasis = Platelet Plug Formation

Platelet plug formation occurs in three phases:
Platelet adhesion - The first phase begins when platelets detect damage to a blood vessel and begin to
adhere to the exposed surfaces.
Platelet release reaction - Once stuck to a site of damage, the platelets begin to change. Firstly they
create extensions so that they can contact each other, and then they release their contents. There are two
types of chemical packages (granules) held within the cytoplasm of platelets: alpha granules that
contain clotting factors, growth factors, and fibroblasts; and dense granules that contain ADP, ATP,
Calcium ions, and Serotonin. Other components are also present within the platelet that aids its work.
Nearby platelets are stimulated into action by the release of ADP and Thromboxane A2 (a
prostaglandin found within platelets). Thromboxane and Serotonin act to cause vasoconstriction.
Platelet aggregation - The ADP acts to make the nearby platelets sticky and adhere to the other
recruited platelets, and when the collection is large enough it creates a platelet plug stopping the loss of
blood through holes in small vessels.

5. Identify other methods (other than Ivy's method) of BT and differentiate as follows:
a. Site of puncture
b. Normal Range
c. Method

M ETHOD S IT E O F NORMAL
PUNCTURE RANGE

D u k e 's M e th o d E a rlo b e 1 – 3 m in u te s

M ie lk e 's M e th oVdo la r s u rfa c e o2f -8 m in u te s

fo re a r m

S im p la te /S u rg icV uo tla r s u rfa c e o2f- 1 0 m in u te s

t M e th o d fo re a r m

Four procedures are currently in use for determining the bleeding time: the Duke method, the Ivy Method,
the Mielke Method and the Simplate or Surgicutt Method.

Duke Method

1. A standardized puncture of the ear lobe is made, and the length of time required for bleeding to cease
while the blood is being blotted every 30 seconds is recorded.

2. A lancet is used to make the puncture.

3. No repeat testing is allowed due to space.

4. Causes apprehension in the patient.

5. This test method is the easiest to perform, but is the least standardized and has the worst precision and
accuracy.

Ivy Method

1. A blood pressure cuff is used to maintain constant pressure within the capillaries to help standardize the
procedure. The cuff is inflated to 40 mm Hg on the upper arm to control capillary tone and to improve the
sensitivity and reproducibility.

2. The forearm is the bleeding time site used.

3. A sterile, disposable blood lancet is used and the length of time required for bleeding to cease is recorded.

4. The greatest source of variation in this test is largely due to difficulty in performing a standardized
puncture. This usually leads to erroneously low results.

Mielke Method

1. Modification of the Ivy Method.

2. A Bard-Parker or similar disposable blade is used, along with a rectangular polystyrene or plastic
template that contains a standardized slit. The blade is placed in a special handle containing a gauge in order
to standardize the depth of the incision.

3. The same procedure as described for the Surgicutt method is employed.

4. Advantages of this method include:

a. That the surgical incision more closely approximates the patient’s hemostatic response to surgery,
when compared to the puncture in the Ivy Method.

b. The depth of the incision can be controlled.

5. Disadvantages of this method include:

a. Cost- scalpel and template required sterilization after each use.

b. Patient apprehension, due to unconcealed scalpel.

c. Small scars might form.

Simplate/Surgicutt Method: Preferred Method

1. Modification of the Ivy Method.

2. The first bleeding time device introduced was the Simplate. The Simplate device has a trigger and spring
method for the blade. The blade has a depth of 1.0 mm and a width of 5.0 mm. Another brand name is the
Surgicutt.

3. Advantages of this method include:

a. Instrument is a sterile, standardized, easy to use device that makes a uniform incision.
b. Instrument is a spring activated surgical steel blade which is housed in a plastic unit. This
eliminates variability of blade incision.

c. This method is the most standardized method of all the bleeding time procedures.

d. Inexpensive

4. Disadvantages of this method include:

a. Slight scarring can occur so patient should be informed.

References
 The Gale Group. Gale Encyclopedia of Medicine, 3rd ed.
 http://www.austincc.edu/mlt/coag/coag_unit6labs_BT_F08.pdf
 http://www.clsi.org/source/orders/free/H45-A2f.pdf
 http://www.ctcd.edu/mlt/mbyrd/plab1023/documents/6bBleedingtime.pdf
 Basic medical laboratory techniques by Barbara H. Estridge, et al.
 Clinical Hematology by Steininger