EXPERIMENT 5 BLEEDING TIME : IVY METHOD

PRINCIPLE:
The bleeding time is the time it takes for a standard wound to stop bleeding. It is a comprehensive
test of platelet action in vivo and is sensitive to abnormalities of platelet numbers and function, to plasma
VIII:vWF deficiencies, and to abnormalities of the vessel wall composition that interfere with platelet
function. The key to precision in the bleeding time is standardization of the wound. This standardization was a
problem with the tests described earlier by Duke and Ivy. Modifications of the Ivy method using a template
such as described by Mielke et al or the commercially available devices that make a standard wound. These
tests require standardization of venous and capillary pressure with the use of a blood pressure cuff inflated to
40 mmHg for the duration of the test. This application of constant venous pressure also increase the sensitivity
of the test
CLINICAL SIGNIFICANCE:
ABNORMAL RESULTS OF A BLEEDING TIME TEST COULD INDICATE:
a) Acquired platelet function defectsconditions that develop after birth and affect how well your blood
platelets work. Your body may produce too many or too few platelets or they may not work properly
b) Blood vessel defectany condition that affects how well your blood vessels transport blood through your
body
c) Hereditary platelet function defectsconditions present at birth that affect how well your platelets
function. Hemophilia is an example
d) Primary Thrombocythemiaa condition in which your bone marrow creates too many platelets
e) Thrombocytopeniaa condition that causes your body to produce too few platelets
f) Von Willebrands diseasethe most common hereditary condition that affects how your blood coagulates
(clots)
Principle:
The bleeding time test is a useful tool to test for platelet plug formation and capillary integrity.
Occasionally, the bleeding time test will be ordered on a patient scheduled for surgery. The bleeding time is
dependent upon the efficiency of tissue fluid in accerlerating the coagulation process, on capillary function
and the number of blood platelets present and their ability to form a platelet plug. Prolonged bleeding times
are generally found when the platelet count is below 50,000/L, and when there is platelet dysfunction.
When a patient is suspected of having a bleeding disorder, several tests are performed to screen defect(s) of
primary hemostasis. These tests include the bleeding time, prothrombin time, activated partial
thromboplastin time, platelet count, fibrinogen, and FDP. Coagulopathies or problems with hemostasis,
such as thrombocytopenia, qualitative platelet defects, vascular abnormalities and von Willebrands disease
can be diagnosed with coagulation tests. 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.
DUKES METHOD
There have been many methods used to measure the bleeding time, dating back to 1910 when Duke
originally described a method in which a lancet was used to make puncture wounds in the earlobe. This test
was difficult to standardize, did not allow space for repeat testing and often caused undue apprehension in
the patient.
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. The prick is about 34 mm deep. The technician then wipes the blood every 30 seconds with a filter paper.
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.
6. Normal Value: 1-3 minutes
IVY METHOD (Normal value: 2-8 minutes)

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 to make a shallow incision that is 1 millimeter deep on the
underside (volar surface) of the forearm.
4) The length of time required for bleeding to cease is recorded.
5) 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 / TEMPLATE METHOD
a. Modification of the Ivy Method.
b. 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.
c. The same procedure as described for the Surgicutt method is employed.
d. Advantages of this method include:
That the surgical incision more closely approximates the patients hemostatic response to surgery,
when compared to the puncture in the Ivy Method.
The depth of the incision can be controlled.
e. Disadvantages of this method include:
Cost- scalpel and template required sterilization after each use.
Patient apprehension, due to unconcealed scalpel.
Small scars might form.
f. Normal Value: 1-8 minutes
SIMPLATE/SURGICUTT METHOD: PREFERRED METHOD (normal value: 2.5-9.5 minutes)

In 1978, a bleeding time device was made commercially available. The first bleeding time device
introduced was the Simplate. Another popular brand is called Surgicutt. It is a sterile, easy-to-use,
disposable instrument that makes a standardized, uniform, surgical incision. This instrument is a springactivated surgical steel blade housed in a self-containing plastic unit from which the blade protracts and
retracts automatically, eliminating the variable of blade incision. Some patients may receive slight scarring
at the incision site and should be so informed prior to performing this procedure. These devices make
standardized incisions and are relatively inexpensive. This is the most standardized method for performing
the bleeding time procedure and is the method of choice.
Modification of the Ivy Method.
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.
Advantages of this method include:
Instrument is a sterile, standardized, easy to use device that makes a uniform incision.
Instrument is a spring activated surgical steel blade which is housed in a plastic unit. This
eliminates variability of blade incision.
This method is the most standardized method of all the bleeding time procedures.
Inexpensive
Disadvantages of this method include:
Slight scarring can occur so patient should be informed.

SOURCES OF ERROR:

(#1-5 : Physiologic errors ; 6-11: other errors)

1) If the patient has taken aspirin or aspirin-containing compounds 7 to 10 days prior to the procedure, the
bleeding time may be prolonged. The technician must determine the patient's history concerning aspirin
ingestion to ensure quality results.
2) Certain drugs like Plavix and Ticlid, which are platelet inhibitors can falsely prolong the bleeding time.
3) Streptokinase - anticlotting substance
4) A prolonged bleeding time may be a result from decreased number of thrombocytes or impaired blood
vessels.
5) The bleeding time is prolonged in thrombocytopenia, hereditary and acquired platelet dysfunctions, von
Willebrand's disease, a fibrinogenemia, severe hypofibrinogenemia, and some vascular bleeding disorders
6) Results may be affected by an improperly performed puncture. A puncture that is too shallow, too deep, or
in an inappropriate location will adversely affect test results.
7) The alcohol must be completely dried before making the puncture. If residual alcohol is on a puncture site,
the bleeding time will be erroneously prolonged.
8) If the technician does not initiate timing of the procedure simultaneously with the puncture, the results will
be adversely affected.
9) If the technician allows the filter paper to touch the wound, the platelet clot may be dislodged, causing
falsely elevated results.
10) If the stopwatch has not been appropriately calibrated, it may keep incorrect time. Stopwatches should be
calibrated on a regular basis as a part of the quality assurance program.
11) The direction of the incision should be consistent. A horizontal incision gives a longer bleeding time than a
vertical incision
NOTE: If bleeding continues for more than 15 minutes, the procedure should be discontinued, and pressure
applied to the wound sites. The bleeding time should be repeated on the other arm. If bleeding has again
not ceased within 15 minutes, the results are reported as greater than 15 minutes.
FALSE POSITIVE RESULTS:
FALSE NEGATIVE:
Blood pressure cuff maintained too high

Blood pressure cuff maintained too low

(>40mm Hg.)
(<40 mm Hg)
Incision too deep, caused by excessive

Incision too shallow

pressure on the incision device.
Disturbing the clot with the filter paper.
Low fibrinogen (<100 mg/dl) or platelet count
(100,00 /mm3)
Drug ingestion affecting platelet function (e.g.
Asprin)
EFFECTS OF ASPIRIN:
CYCLO-OXYGENASE (COX) also plays a role in cessation of bleeding. Blood clotting is the
result of a complex mechanism which involves many different cells, including a type known as platelets.
When blood vessels are damaged or are diseased, platelets clump together over the hole or vessel tear to
facilitate repair. COX activates a chemical known as thromboxane A2 that causes platelets to stick together
to form a 'plug' over the damaged area. The aggregation of platelets (plug), in concert with the clotting
process, results in a fibrin clot which stops bleeding and aids repair of the blood vessel.
Aspirin inhibits CYCLO-OCYGENASE, thereby reducing the ability of platelets to aggregate.
This is why aspirin is known as a blood thinner or anti-platelet agent. It is also why increased bleeding is
a side effect of aspirin. Although major bleeding is rare, aspirin can cause this. Blood thinning however, is
useful to prevent heart attacks and strokes.