PROTHROMBIN TIME

I. DEFINITION
- It is a protein produced by the liver for clotting of blood. Prothrombin production
depends on adequate vitamin K intake and absorption.
- During the clotting process, prothrombin is converted to thrombin.
- The prothrombin content of the blood is reduced in patients with liver disease.
- IT IS ONE of the four most important screening tests used in diagnostic coagulation
studies.
- It directly measures a potential defect in stage II of the clotting mechanism (Extrinsic
coagulation system) through analysis of the clotting ability of five plasma
coagulation factors (prothrombin, fibrinogen, factor V, Factor VII, and factor X).
- It is USED to evaluate disfibrinogenemia, evaluate the heparin effect and coumarin
effect, liver failure, and vitamin K deficiency.

II. Indication /Contraindication
- 1.Conditions that cause increased PT include:
a. Deficiency of factors II (prothrombin) , V, VII, or X
b. Vitamin K deficiency, newborns of mother with vitamin K deficiency
c. Hemorrhagic disease of newborn
d. Liver Disease (eg, alcoholic hepatitis), liver damage
e. Current anticoagulant therapy with warfin (Coumadin)
f. Biliary Obstruction
g. Poor fat absorption (eg, sprue, celiac disease, chronic diarrhea)
h. Current Anticoagulant therapy with heparin
i. DIC
j. Zollinger-Ellison Syndrome
k. Hypofibrinogenemia (factor I Deficiency), dysfibrinogenemia
l. (Circulating anticoagulants), lupus anticoagulant
m. Premature newborns
- 2. Conditions that do not affect the PT include:
a. Polycythemia vera
b. Tannin Disease
c. Christmas disease (factor IX deficiency)
d. Hemophilia A (factor VIII deficiency)
e. Von Willebrands disease
f. Platelet disorders (idiopathic thrombocytopenic purpura)

III. Equipment Used / Procedure
- 1. Draw a 5mL venous blood sample (by the two tube technique) into a tube
containing calcium-binding anticoagulant (sodium citrate). The ratio of sodium
citrate to blood is critical.
2. Use blue-topped vacuum tubes that keep prothrombin levels stable at room
temperature for 12 hours if left capped (vacuum intact). Place specimen in
biohazard bag.


IV. Nursing Responsibities
- Pre-Test
- Explain the purpose, procedure and need for frequent testing.
- Emphasize the need for regular monitoring through frequent blood testing if long-
term therapy is prescribed.
- Know what are the drugs been taken by the patient.
- Instruct the patient never to start or discontinue without doctors permission.
- Counsel regarding Diet.
- Remember that these guidelines also apply to aftercare.

- Post-Test
- Interpret test outcomes and monitor appropriately with follow-up testing and
observation.
- Avoid IM injections during anticoagulant therapy because hematomas may form at
the injection site.
- As the prothrombin time increases to upper limits (>30 seconds), assess carefully for
bleeding from different areas; this may require neurologic assessment (if cranial
bleeding is suspected) lung assessment and auscultation, gastrointestinal and
genitourinary assessments
- Instruct the patient to observed for any bleeding from gums, blood in the urine, or
other unusual bleeding
- Advised that the care should be exercised in all activities to avoid accidental injury.
- Alert patients who are being monitored by PT for long-term anticoagulant therapy
should not take any drugs unless they have been specifically prescribed.
- Make changes in exercise intensity gradually or not at all. Active Sports and contact
sports should be avoided because of potential injury.


V. Possible Complications
1. Diet: EXCESSIVE ingestion of green, Leafy vegetables increases the bodys
absorption of Vitamin K, whick promotes the blood clotting.
2. Alcoholism or excessive alcohol ingestion prolongs PT levels.
3. Diarrhea and Vomiting decrease PT because of dehydration.
4. Quality of Venipuncture: PT can be shortened if technique is traumatic and
tissue thromboplastin is introduced to the sample and If collection tube is not
filled properly.
5. Influence of prescribed medications: antibiotics, aspirin, cimetidine, isoniazid,
phenothiazides, cephalosporins, cholestyramines, phenylbutazone,
metronidazole, oral hypoglycemic, phenytoin
6. Prolonged storanged of plasma at 4C activates factor VII and shortens PT

VI. Normal Values
- PT: 11.0 - 13.0 seconds (can vary by laboratory)
- The INR is typically used to monitor patients on warfarin or related oral
anticoagulant therapy. The normal range for a healthy person not using warfarin
is 0.81.2, and for people on warfarin therapy an INR of 2.03.0 usually targeted,
although the target INR may be higher in particular situations, such as for those
with a mechanical heart valve. If the INR is outside the target range, a high INR
indicates a higher risk of bleeding, while a low INR suggests a higher risk of
developing a clot.
- Therapeutic levels are at a P/C ratio of 2.0-2.5. Recommended therapeutic ranges
are shown here:

THERAPEUTIC CONTEXT
INR Target
Preoperative oral anti coagulant started 2 weeks before surgery
Non-hip surgery 1.5-2.5 2.0
Hip Surgery 2.0-3.0 2.5
Primary and secondary prevention of deep vein thrombosis 2.0-3.0 2.5
Prevention of Systemic embolism in patients with atrial fibrillation 2.0-3.0 2.5
Recurrent systemic embolism 2.0-4.5 3.5
Prevention of recurrent deep vein thrombosis
(two or more episodes)
2.0-4.0 3.0
Cardiac Stents 2.0-4.5 3.5
Prevention of arterial thrombosis, including patients with
mechanical heart valves
2.0-4.5 3.5
INR (International Normalized Ratio): A comparative rating of PT ratios


ISI (International Sensitivity Index): A comparative rating of thromboplastin
VII. Significant Results / Interpretations
PT
RESULT PTT RESULT EXAMPLES OF CONDITIONS THAT MAY BE PRESENT
Prolonged Normal Liver disease, decreased vitamin K, decreased or defective factor VII, chronic low-
grade disseminated intravascular coagulation (DIC), anticoagulation drug (warfarin)
therapy
Normal Prolonged Decreased or defective factor VIII, IX, or XI, von Willebrand disease (severe type),
presence of lupus anticoagulant
Prolonged Prolonged Decreased or defective factor I, II, V or X, severe liver disease, acute DIC
Normal Normal or
slightly
prolonged
May indicate normal hemostasis; however, PT and PTT can be normal in conditions
such as mild deficiencies in other factors and mild form of von Willebrand disease.
Further testing may be required to diagnose these conditions.


REFERENCE: A MANUAL OF LABORATORY AND DIAGNOSTIC TESTS
7
TH
EDITION BY FRANCES FISCHBACH
http://en.wikipedia.org/wiki/Prothrombin_time
http://www.youtube.com/watch?v=wyWe9Je9Cfw please include this video.