Indian J Pediatr (September 2012) 79(9):12331235 DOI 10.

1007/s12098-011-0644-1

CLINICAL BRIEF

Clotting Screen Requests in Pediatrics

Jecko Thachil & Gail Ann Whitehead

Received: 25 May 2011 / Accepted: 30 November 2011 / Published online: 15 December 2011 # Dr. K C Chaudhuri Foundation 2011

Abstract Coagulation parameters are routinely requested among all age-groups in pediatrics to identify abnormalities which may contribute to bleeding manifestations or thrombotic complications. These results are vital especially in the management of sick children although in some cases, they may be helpful in identifying those with inherited bleeding disorders and to confirm or exclude non-accidental injury. Despite the usefulness of these screening tests, it is important that the professionals who are responsible for the care of children interpret the results of these tests in the most accurate manner to avoid unnecessary further investigations and inappropriate management. Keywords Children . Pediatrics . Thrombosis

issues before, during and after the collection of the clotting specimens. Before Ordering the Clotting Screen Probably, the most important part of the ordering of a clotting screen is to assess the need for the test. If indicated, it is also necessary to explain clearly the clinical situation and the possible diagnosis considered on the request form (discussion with the hematologist may be useful in difficult situations). This is important for channelling the samples in the coagulation laboratory for the appropriate initial and secondary tests (if the initial tests are abnormal). For e.g., if the child is in intensive care, there is a likelihood of acquired deficiency of clotting factors compared to a child with joint bleeds where a single factor deficiency is more likely. Repeat sampling may be a problem in neonates where the volume of sample, which can be collected, is limited and repeated bleeding may result in anemia. Repeated tests can also cause unnecessary bruising in a child with bleeding disorder and should be avoided. Before Collection of the Sample It is preferable for pediatric units to have dedicated clotting tubes for the collection of blood. But prior to blood sampling, the effect of hematocrit on coagulation tests has to be borne in mind as it might necessitate a different but specially prepared specimen bottle. This is more of a concern in the cardiac patients who may run a higher hemoglobin value. It has been demonstrated that once the hematocrit is above 0.55, the coagulation results can be misleading [2]. The effects of a higher hematocrit on the clotting screen are due to a dilutional effect of plasma and an interference effect of the higher final citrate concentration.

Introduction The accurate diagnosis of hemostatic abnormalities using a clotting screen is critical to the care of sick neonates and children, while their exclusion is paramount when a child is being assessed for non-accidental injuries. Despite the usefulness of these tests, there are inherent problems related to the collection, analysis and interpretation of the coagulation profile and as such there is a need for awareness of the limitations of these tests [1]. These can be divided into
J. Thachil (*) Department of Hematology, Royal Liverpool University Hospital, Prescot Street, Liverpool, UK L7 8XP e-mail: jeckothachil@yahoo.co.uk G. A. Whitehead Department of Child Health, Macclesfield General Hospital, Macclesfield, UK

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Indian J Pediatr (September 2012) 79(9):12331235

Hence for patients with high hematocrit values, citrate concentrations must be adjusted and separate clotting tubes must be prepared [3]. (Appendix 1). Under filling of the clotting tubes may also significantly affect the APTT and PT, resulting in artefactual prolongation of results [5]. During Collection of the Sample During the collection of samples (especially capillary specimens), caution is to be exercised to prevent the activation of the clotting system. Free flowing blood is preferably collected after allowing the first drop or two to be blotted off. Excessive squeezing of the skin puncture site may cause dilution of the blood with extra cellular fluid. Hemolysis may also occur if there is excessive milking and can cause interference with light absorbance during the testing [4]. If a winged butterfly system is used to draw the blood, the long tubing can contain dead space air, which needs to be cleared before filling the specimen tube to avoid under filling. This can be done by allowing the first few drops of blood to be collected for other tests like blood count or blood cultures and collecting the free flowing blood for coagulation testing. A venepuncture technique is most ideal though excessive pull on the syringe with bubbling of air into the tube may also affect the coagulation results. Similar problems also can occur with arterial or central venous lines, which may have heparin in the lumen as locks. This minimal amount of heparin can prolong the coagulation results especially the APTT [6]. Thus, when a central line is used for drawing blood, it has been recommended that it should be flushed with saline, and then the dead space volume must be drawn and discarded prior to specimen collection [5]. After Collection of the Sample Hypothermia and acidosis, which may occur commonly in children in the intensive care units, from where clotting tests are most often requested, also have significant effects on the clotting system and thus clotting results. Acidosis specifically interferes with the assembly of the coagulation factor complexes and reduces the activity of the factor Xa-Vaprothrombinase complex by 50% at pH 7.2, 70% at pH 7, and 90% at pH 6.8 [7] Hypothermia also reduces the enzymatic activity of plasma coagulation proteins and has a big effect on clotting by preventing the activation of platelets [8]. It is important to bear in mind, these two factors, especially when the results obtained are within normal range in a sick child. Interpretation of the Results Interpretation of the results also requires caution. Values have to be interpreted in the light of normal physiological

immaturity of the hemostatic mechanism. In particular, an understanding of normal for different age groups is critical to both full blood count examination and coagulation studies. This may be more of a problem in hematology laboratories, which cater for both adults and children as in a district general hospital. The normal ranges for premature babies, neonates, infants, toddlers and teenagers differ and it is important to have normal reference ranges for these different age groups [9]. Monagle et al. has also demonstrated the need for coagulation laboratories to develop age-related reference ranges specific to their own testing systems especially because coagulation testing is known to be sensitive to changes in individual reagents and analysers [10]. They also provide reference ranges which may be consulted for comparisons. Thus, more care has to go in, before, during and after the collection of a coagulation screen to obtain the most accurate, meaningful and relevant result.

Conflict of Interest None.

Role of Funding Source

None.

Appendix 1

Reference formula to calculate the amount of citrate depending on the hematocrit4 To calculate the amount of citrate to be present in the blood drawing tube or syringe, the following formula has been recommended for use in laboratories C = (1.85 103) (100 Hct) (Vblood); Where C is the volume of citrate remaining in the tube, Hct is the hematocrit of the patient, and V is the volume of blood to be added. For e.g., if a 5-mL tube is used, the volume is 4.5 mL. A nomogram is also available in Clinical and Laboratory Standards Institute.

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