Pre-Analytical Variables in Coagulation Testing

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Pre-analytical Variables in Coagulation Testing

Associated With Diagnostic Errors in
Hemostasis
Emmanuel J. Favaloro, PhD, MAIMS, FFSc (RCPA); Dorothy M. (Adcock) Funk, MD;
Giuseppe Lippi, MD
Lab Med. 2012;43(2):1-10.
Abstract and Introduction

Abstract
The use of modern laboratory instrumentation with high levels of test reliability and appropriate quality assurance
measures will lead to very few analytical errors within hemostasis testing. Nevertheless, incorrect or inappropriate
test results are still reported, often due to events outside the control of the laboratories performing the tests. This
is due primarily to pre-analytical events associated with sample collection and processing, as well as postanalytical events related to the reporting and interpretation of test results. This review focuses on the preanalytical phase, highlighting contributory elements and providing suggestions on how problems can be minimized
or prevented, thereby improving the likelihood that reported test results actually represent the true clinical status
of the patient rather than that of an inappropriate sample. This review should be of value to both laboratory
personnel and clinicians because an appreciation of these issues will enable the optimal clinical management of
patients.
Introduction
Modern instrumentation is generally capable of providing highly accurate test results. Utilized with appropriate
internal quality control and external quality assurance measures, analytical errors within hemostasis testing are
generally minimal. Nevertheless, incorrect or inappropriate test results will on occasion be reported to clinicians,
most often due to circumstances beyond the control of the laboratories performing these tests. Overall, a
significant impact on patient care arising from diagnostic errors has been estimated to arise in around 9% to 15%
of errors, while the likelihood of inappropriate care has been described in 2% to 7% of such cases. [1] Many of
these errors will originate due to the inappropriate collection, handling, or processing of samples referred for
testing and sometimes because testing has been initiated on the wrong patient or at the wrong timepoint. In these
instances, test results will accurately reflect the status of the test sample, but conversely they will not accurately
reflect the clinical status of the patient being investigated. These issues are referred to as pre-analytical variables.
Consequences of Pre-analytical Issues

It is inherently challenging to establish a direct relationship between spurious test results and patient outcomes
since laboratory errors do not always and necessarily translate into serious harm for the patient as may occur in
cases of mishandled surgery or inappropriate drug therapy. Nevertheless, the consequences of incorrect test
results might still be clinically meaningful and lead to several unwanted clinical outcomes or adverse economical
consequences, and place laboratories at risk. [2] The seriousness of the potential consequences relates to the test
being performed, the extent of the difference between the reported result and the true result, as well as the ability
of laboratory personnel and clinicians to recognize the issues. [3,4] Consequences may be particularly serious for
errors related to specialized hemostasis tests because these assays are often considered "diagnostic." Thus, a
patient might be diagnosed with a particular disorder, when he/she does not have it (ie, false-positive test result
obtained) or a patient with a true disorder might be missed (ie, false-negative test result obtained). Both situations
will cause adverse consequences for both patients and the health care system. As examples, 1) a false-negative
antiphospholipid (aPL) antibody or lupus anticoagulant (LA) test result in a patient with the aPL antibody
syndrome (APS) may lead to lack of appropriate treatment with anticoagulant therapy to prevent a future
thrombosis; and 2) a false diagnosis of von Willebrand disease (VWD) may lead to inappropriate treatment with
factor concentrates or to a lifelong label of a congenital disorder affecting quality of life. Serious consequences
may also result due to errors in routine coagulation testing. For example, 1) a falsely prolonged "screening"
coagulation test might influence a clinical decision to undertake further costly and time consuming (eg, "specific
diagnostic") investigations, unnecessarily delay invasive procedures, and raise unnecessary anxiety in the patient
being investigated; 2) a false-normal screening test result might prevent further evaluation of factor assays, thus
incorrectly discounting hemophilia and possibly placing a patient at an unjustified risk of bleeding with invasive
procedures (ie, surgery, dental extraction, biopsies); and 3) a false low or high coagulation test time in a patient
being monitored for anticoagulant therapy may lead to subsequent incorrect dosing of anticoagulant therapy with a
risk of thrombosis or bleeding depending on the direction of the error.
Overview of Hemostasis, Laboratory Testing, and Pre-analytical Issues

Hemostasis is commonly thought of in terms of "coagulation pathways" or as a surrogate of "coagulation."
However, hemostasis is far more complex than "coagulation," which in essence reflects clot formation, as it
incorporates several components unrelated to the "coagulation" process. The components of hemostasis can be
considered within the context of Virchow's Triad, or as a composite of primary hemostasis (platelet plug formation,
von Willebrand factor [VWF]/platelets/subendothelial components), secondary hemostasis (fibrin clot formation,
procoagulant "clotting" factors, and the natural anticoagulants) and fibrinolytic pathways. [5,6]
The modern hemostasis laboratory performs a large number of distinct tests, often using a variety of
methodologies (). All hemostasis laboratories perform routine coagulation tests comprising the prothrombin time
(PT)/international normalized ratio (INR) and the activated partial thromboplastin time (APTT), sometimes
supplemented by specific fibrinogen assays, and occasionally thrombin time (TT) assays. Most routine test
laboratories also perform D-dimer assays. These tests are variably performed to investigate hemostasis in
patients suspected of having a potential dysfunction in the secondary hemostasis pathway, either congenital (eg,
hemophilia) or acquired (eg, disseminated intravascular coagulation [DIC]). [5,710] This is because PT/INR, APTT,
and TT are sensitive to deficiencies or defects in various procoagulant factors. Thus, the PT/INR is sensitive to
factors (F) I, II, VII, V, and X, and the APTT to F I, II, V, VIII, IX, X, XI, and XII. The single or compound deficiency
or absence of most of these factors will lead to an increased tendency to bleeding and will occasionally define
hemophilia (eg, deficiency in FVIII, hemophilia A; deficiency in FIX, hemophilia B). In contrast, an excess of some
procoagulant factors (eg, FVIII, FIX, and FXI) may lead to thrombophilia. [11] Although the PT/INR and APTT are not
highly sensitive to elevations in procoagulant factors, a short APTT is sometimes indicative of this, and hence
may reflect an increased risk of thrombosis. [8,12,13] The PT/INR is also used to monitor vitamin K antagonists
such as warfarin, [7,14] and the APTT to monitor unfractionated heparin. [8] Indeed, these tests are more often
performed for monitoring anticoagulant therapy than for assessing secondary hemostasis. Other tests performed
by hemostasis laboratories in general comprise a battery of specific "diagnostic" assays (largely listed in ).
Table 1. Summary of Hemostasis Tests and Sample Requirements
Comprise
Usually Performed Via
Sample Type
Citrate anticoagulated plasma post single

centrifugation
A. Routine coagulation tests
PT/INR, APTT, TT, fibrinogen
Clot-based tests, automated

instrument, primary collection
tube (sometimes separated
plasma)
D-Dimer (D-D)
ELISA or ELFA or
agglutination (primary or
secondary tube)
B. Specialized Hemostasis
Tests
Factor assays (ie, II, V, VII,
VIII, IX, X, XI, XII), factor
inhibitor assessments, protein

instrument
Separated citrate anticoagulated plasma, post

single centrifugation (usually post freezing)
S, protein C
VWF tests
ELISA, immunoassay, or
agglutination
Protein C, protein S,
antithrombin
ELISA, immunoassay, clot

based, or chromogenic assays
single (or preferably double) centrifugation
(usually post freezing)
Heparin (anti-Xa) assay
Chromogenic assays
APCR

instrument
LA

instrument

double centrifugation (usually post freezing)
Solid phase aPL tests

including aCL and ab2GPI
ELISA or immunoflourescent
assay
Separated serum preferred; separated citrate

anticoagulated plasma post single
centrifugation sometimes acceptable. Usually
post freezing.
Platelet function tests
Specialized instrumentation
Citrate anticoagulated whole blood or special

processing required.
Genetic thrombophilia tests
EDTA or citrate anticoagulated whole blood or

special processing required
Comprise
Sample Type

centrifugation

plasma)
D-Dimer (D-D)
ELISA or ELFA or
secondary tube)
Tests
S, protein C

instrument
VWF tests
agglutination
antithrombin

Chromogenic assays


APCR

instrument
LA

instrument


assay

post freezing.


The large number of distinct tests involving a variety of methodologies may result in significant problems when
unsuitable samples are submitted for testing. Although guidelines are available for how to manage and when to
reject unsuitable specimens, [15,16] it is not always clear when unsuitable samples have been received. Preanalytical problems can arise at any point prior to sample testing, including (but not limited to) sample collection,
handling, transportation, processing, and storage. Whereas analytical errors are largely avoided or intercepted by
using appropriate test methodologies and by incorporation of appropriate control measures, pre-analytical issues
present a more difficult scenario for laboratories as they are often outside the control of the laboratory performing
the tests, and often the laboratory is unaware that the adverse pre-analytical event has occurred. Thus, the
laboratory may issue a test result with the best of intentions as reflecting an accurate patient-related result, but
this may not be the case. Clinicians would be even less aware of the issue of pre-analytical variables than the
laboratory, and would base their clinical actions on the test result received (as reflecting a true and correct result).
For this reason, guidelines for specimen collection and handling must be strictly followed and deviations avoided
unless their impact, or lack thereof, on coagulation testing is known.
Appropriate Sample Collection, Processing, and Storage

These are critical to the attainment of appropriate test results but are often neglected, overlooked, or poorly
applied.
Positive Patient and Sample Identification
The importance of proper patient identification cannot be overemphasized. In an outpatient setting, the principle of
"double identifiers" should be used, specifically; the conscious patients should be asked to identify themselves
and also produce some form of identification. Within the hospital, positive patient identification should follow
institutional rules and will typically entail electronic or bar-code methods to reduce the risk of patient
misidentification. Other guidelines to ensure positive patient and sample identification include those related to
printing tube labels; matching patient identification with the patient's full name, and an additional identifier, such
as date of birth or medical record number; and identification of collection date and time. [16,17]
Sample Collection
All tests have specific collection requirements. Sample collection issues might arise because of inexperience or
time pressures when collectors are faced with a busy clinic and multiple collection requirements. Most samples
referred for coagulation testing must be drawn into citrate-based anticoagulant tubes (generally 105109 mM or
129 mM sodium citrate, also referred to as 3.2% or 3.8%, respectively). The current Clinical and Laboratory
Standards Institute (CLSI) guidelines [16] favor the use of the lower citrate concentration, except for specific
applications. [4,16] Specimens collected in 129 mM (3.8%) buffered sodium citrate may overestimate the PT and
APTT and underestimate fibrinogen if the normal range is based on 3.2% citrated samples. [18] Conversely,
samples collected into 129 mM (3.8%) citrate may provide a more stable sample for assessing antiplatelet (eg,
aspirin) therapy response using the PFA-100. Sometimes there is no apparent difference in relation to testing (eg,
anti-Xa [heparin] testing) based on citrate concentration. The major recommendation therefore is that laboratories
standardize to 1 citrate concentration and develop normal ranges appropriate for that concentration. This
standardization should include all components of the assay (eg, including determination of patient PT, mean
normal PT [NMPT], and international sensitivity index [ISI] for the INR).
Coagulation samples should preferably be collected before other test samples are drawn, if these contain stronger
anticoagulant agents such as ethylenediaminetetraacetic acid (EDTA) (for a complete blood count), lithiumheparin (for clinical chemistry testing), as well as clot activators (ie, thrombin), since these materials may
contaminate a subsequent coagulation test sample. A specific sequence of tube collections (so-called "order of
draw") is provided by the CLSI. [19] The old dogma that the first collection tube should be discarded may not
generally be required, as evidence for differential effects on coagulation assays are lacking. [20] Nevertheless, a
discard tube is needed if the sample is drawn using a winged collection with variable tubing length so air in the
tubing is not introduced into blood collection tubes leading to under-filling. [16,21] Tubes should be adequately filled
(to the mark noted on the tube if provided) or to no less than 90% of this total volume. Under-filling may cause
significant sample dilution and may also provide falsely prolonged clotting times due to the excess calciumbinding citrate present. This effect depends on the citrate concentration, the tube size, and the test performed
being more pronounced with 3.8% citrate tubes and small volume (pediatric) collection tubes. [22,23] Sample
dilution will also lead to under-estimation of quantitative test results (eg, clotting factor levels).
Blood should never be transferred from 1 collection tube to another in an effort to provide the required complete fill
volume. This is true even if 2 sodium citrate tubes are combined, as this may lead to doubling up of anticoagulant
citrate levels and further dilution of the plasma sample. The introduction of stronger anticoagulants (eg, EDTA or
lithium-heparin) or clot activators (eg, thrombin) must also be avoided, and this will occur if blood from non-citrate
collection tubes is added to citrate tubes.
Samples should be mixed thoroughly (but gently) by 3 to 6 end-over-end tube inversions to ensure adequate
mixing of test sample with anticoagulant [19] and to prevent sample clotting. Insufficient mixing may have a greater
effect on specialized hemostasis assays performed some time after collection than on basic coagulation tests
performed soon after collection. Conversely, too vigorous mixing (eg, by shaking of tubes) might lead to in vitro
hemolysis or spurious factor activation resulting in false shortening of test clotting times and even possible false
elevation of clotting factor activity (eg, FVII).
Some tests referred to hemostasis laboratories may require sample matrices other than sodium citrate
anticoagulated plasma, leading to additional scope for pre-analytical error. For example, while the test sample for
LA testing must be citrate anticoagulated plasma, the preferred test sample for solid phase testing of aPL
antibodies, such as anticardiolipin (aCL) antibody and anti-beta-2-glycoprotein I (aB2GPI), in serum. As all of
these different tests might be requested for a patient being investigated for APS, problems may arise should the
laboratory inadvertently perform LA testing using the serum sample.
Other issues arising from blood collections include difficult collections, or those derived from central venous lines,
leading to partially clotted, hemolyzed, or activated samples, or samples diluted by saline or contaminated with
heparin. Collections from venous lines should include a process for flushing and/or discarding the initial collection
volumes. Size and type of needle used may also influence results and too large (less than 16 gauge) or too small
a needle bore (greater than 25 gauge) should be avoided, and heparinized needles (sometimes used for blood gas
collection) not used. [24]
Sample Transport
Samples should be transported as per current guidelines, [16] non-refrigerated at ambient temperature (1522C) in
as short a time as possible. Ideally, testing for routine coagulation tests like the PT and the APTT should be
accomplished within 4 hours of collection, although allowable tolerances may be greater than this. [25,26] However,
APTT testing for unfractionated heparin monitoring should preferably be processed within 1 hour due to the
potential for heparin neutralization by platelet releasates. [16,27,28] Extremes of temperature (ie, both refrigerated or
high) should be avoided. Delays in transport may affect in particular the labile factors (FV, FVIII), leading to
prolonged clotting times and in vitro loss of factor activity. [29] In such cases, local centrifugation and separation of
plasma followed by freezing and frozen transport of the plasma should be considered.
Sample Processing and Storage
This should also in general proceed as per current CLSI guidelines, [16] noting limitations according to which test
is being performed. Most coagulation-based tests, including PT, APTT, and clotting factor assays, are performed
on plasma derived from once-centrifuged samples (). Some samples, such as those for LA testing, should be
double centrifuged to ensure platelet-free preparations prior to freezing. [30] Centrifugation should essentially be at
an ambient temperature (15C-22C), but this is sometimes difficult to control. Non-refrigerated centrifuges are
adequate, providing they do not overheat. Alternatively, refrigerated centrifuges may be used but should be set to
maintain ambient temperatures, rather than low temperatures, which can lead to platelet activation and adverse
effects. Nevertheless, refrigerated centrifugation does not appear to affect routine coagulation tests when testing is
performed soon after centrifugation. Centrifugation should ideally be at 1500 g for a minimum of 1015 minutes. [16]
Shorter centrifuge times might be acceptable for routine coagulation tests performed immediately postcentrifugation when there are no subsequent test requirements (ie, plasma not to be frozen or processed for
additional assays). Using centrifugal forces greater than 1500 g are not recommended as this may induce platelet
activation and lysis of RBCs. The use of centrifuge breaks should also be avoided or monitored to avoid remixing
of test samples, particularly if plasma is to be frozen, since there is a potential for hemolysis and platelet
contamination, which may subsequently affect most hemostasis assays.
Comprise
Sample Type

centrifugation

plasma)
D-Dimer (D-D)
ELISA or ELFA or
secondary tube)
Tests
S, protein C

instrument
VWF tests
agglutination
antithrombin

Chromogenic assays
APCR

instrument
LA

instrument




assay

post freezing.


Testing generally proceeds using the once-centrifuged test sample in the primary collection tube or on the oncecentrifuged separated plasma sample before or after freezing (). For some assays, samples should be double
centrifuged ("double-spun"), which entails the re-centrifugation of the separated plasma, and re-separation of this
double-spun plasma from any residual cellular pellet prior to freezing. Since all plasma-based hemostasis tests
can safely be performed on double-spun material, it might be prudent to institute this process as a general
laboratory policy for any plasma that will be frozen prior to testing. Use of filtered plasma is no longer
recommended for LA testing, since this might produce spurious test results with some assays, as highlighted
later. [30] Lastly, some tests require additional special differential processing (eg, platelet function testing). [31]
Comprise
Sample Type

centrifugation

plasma)
D-Dimer (D-D)
ELISA or ELFA or
secondary tube)
Tests
S, protein C

instrument
VWF tests
agglutination
antithrombin



Chromogenic assays
APCR

instrument
LA

instrument

assay


post freezing.


The stability of coagulation samples varies depending on a number of variables such as the blood collection
system, whether the samples are stored as whole blood or centrifuged, the temperature at which samples are
maintained during storage, the reagent/instrument system used for analysis, and the test parameter to be
analyzed. For example, whole blood stored up to 2448 hours prior to centrifugation has been reported as
acceptable for many hemostasis tests (although not for FV, FVIII, and protein S), [25,32] but other studies have
reported significant changes in some test results over such time periods. [4] Moreover, storage of refrigerated whole
blood is now actively discouraged and leads to activation events affecting FVII, FVIII, VWF, and possibly others.
[16,33]
In general, to afford the greatest sample integrity, samples should be processed as quickly as possible (ideally
within 1 hour of collection) and testing performed within 4 hours of procurement (or else be processed by
centrifugation and plasma frozen). During this short-term storage, whole blood samples should be kept capped
and maintained at room temperature. If testing is not to be performed within about 4 hours for the APTT and 24
hours for the PT, the plasma should be separated from the cellular fraction of the once or twice-centrifuged
sample, without disturbing the cell pellet. For many tests of hemostasis, the separated plasma can be safely
frozen for later testing. Separated plasma can generally be maintained at room temperature or refrigerated for a
few hours without an adverse effect on coagulation. Otherwise, separated plasma samples should be frozen.
Frost-free freezers with automatic defrost cycles are generally unsuitable, since they cycle freeze-thaw events to
maintain the frost-free environment, and this adversely affects subsequent coagulation tests. However, the use of
frost-free freezers for patient samples is acceptable where freezers are monitored by a continuous-monitoring
temperature recording device, or a minimum-maximum thermometer, enabling the laboratory to show the
acceptable temperature range is never exceeded. When storing plasma, the lower the freezer temperature, the
longer the specimens can be maintained for future testing. As a general rule of thumb, testing for samples
maintained at around -20C should be finalized within 24 weeks of storage, whereas testing for samples
maintained at around -80C can occur several months and sometimes years later (useful for research studies and
prospective trials). [34]
Controlled Thawing of Frozen Plasma Samples
Previously frozen samples should be rapidly thawed in a 37C water bath for 510 minutes or until completely
thawed. [4,16] Close monitoring during this time is necessary to avoid inadequate or excessive incubation at 37C.
Sample integrity may be compromised if samples are either not completely thawed or if maintained too long at
37C. Furthermore, water baths must be properly maintained to make certain they are not inadvertently
maintained at a higher temperature because this may lead to deterioration of coagulation factor activities and
spurious coagulation test results. Once samples are thawed, it is imperative they are thoroughly and adequately
mixed prior to testing.
Typical Issues Related to Inappropriate Sample Collection, Processing, and Storage

Incorrect Patient Collected or Wrong Label Attached
Patient misidentification errors are potentially associated with the worst clinical outcome due to the potential for
misdiagnosis and inappropriate therapy. Whenever misidentification is suspected, the laboratory might be able to
identify this as being the case by investigation, but the safest approach is generally recollection and retesting.
Incorrect Anticoagulant Matrix Collected or Provided to the Laboratory
Although serum, heparin, or EDTA samples provided as a primary collection tube can be quickly identified as
unsuitable by the laboratory, collection into the wrong anticoagulant may be missed when samples are provided in
secondary tubes, or if samples have been mixed or transferred or added to a primary citrate tube. [4,16] The
potential consequences will differ according to the sample type received and the tests being performed as will the
ability of laboratory personnel to recognize an incorrect sample. For example, testing for routine coagulation tests
such as the PT and APTT will result in no clot or prolonged clotting times, but effects on other test results may be
more subtle. Thus, testing of normal serum for VWF tests will not provide extreme changes but might instead give
rise to patterns consistent with Type 2 VWD. Similarly, testing of heparin or EDTA plasma may derive "plasmalike" test results for D-dimer and some VWF tests but a false impression of absent FVIII activity by 1-stage
clotting assays.
Serum or Clotted Samples
Samples in which the blood is slow to fill the collection container, where there is prolonged use of a tourniquet, or
considerable manipulation of the vein by the needle may be prone to develop a clot in vitro. Clots may also
develop when samples are incompletely mixed immediately following collection or in under-filled tubes. Although
modern laboratory instrumentation is increasingly being equipped with various additional sensors (eg,
bubble/volume/clot), samples yielding long clotting times should routinely be checked for the presence of a clot,
either visually or preferably by inserting 2 wooden applicator sticks into a whole blood sample. The presence of a
clot is a cause for rejection of the specimen. Serum will lead to loss of fibrinogen and many other coagulation
factors (notably FII, FV, and FVIII) as well as differential loss of high molecular weight VWF (, and ). [35,36] Serum
may also yield high values for some factors (eg, FVII) due to activation. Testing of serum will therefore lead to noncoagulation in tests such as the PT, APTT, and TT, possible diagnosis of coagulation factor deficiencies, false
diagnosis of certain subtypes of VWD, and problems with LA identification. Alternatively, test results using serum
might be normal with some other tests. Testing of partially clotted blood may lead to prolongation or shortening of
coagulation tests depending on the extent of fibrinogen/factor loss vs activation events, and is often harder to
identify.
Table 2. Summary of Differential Effects of Testing Different Sample Types on Select Hemostasis Tests
Sample Type
Routine Coagulation Tests
Potential
Consequences Potential Consequences On
On Factor
Other Hemostasis Tests
Assays
EDTA plasma
Prolongs PT and APTT, and

occasionally TT. Might influence
fibrinogen and D-dimer assays
False impression of inhibitors to

False low levels FV and FVIII, and may show
(especially FV time dependence (ie, enhanced
and FVIII)
with incubation); false LA
feasible
Serum or fully
clotted coagulation
sample
No fibrinogen, so no clot in PT, APTT,

or TT. False impression of
afibrinogenemia. D-dimer assays can
be affected especially if testing
delayed
False low levels

False impression of factor
(especially FII,
inhibitors or VWD; false LA
FV, and FVIII);
feasible
false high FVII
Partially clotted
coagulation sample
Depending on relative extent of platelet

activation, hemolysis and loss of
False low factor
Flow obstructions in PFA-100
fibrinogen might lead to false
levels or false
testing
prolongation of PT, APTT, and TT, or
high factor VII
false shortening of APTT
Underfilled primary
Will typically prolong PT, APTT, and
citrate anticoagulant TT. May underestimate fibrinogen and
tube
D-dimer
False low factor False low levels of most

hemostasis tests likely
levels likely
Vitamin K-deficient
plasma, patient on
Prolongs PT and APTT (PT raised
vitamin K antagonist
>APTT raised)
False low
factors
(especially FII,
False low protein C (potentially

different effect with clot-based
assays vs chromogenic
therapy, liver
disease sample
FVII, FIX, FX)
Heparin
'contamination'
Prolongs PT, APTT, and TT (usually
(either ex-vivo or due TT raised >APTT raised >PT raised),
to collection tube
false low fibrinogen
error)
Reduced
factors
(especially
FVIII, FIX, FXI,
FXII)
assays); false low protein S;

false APCR; false LA feasible
False low Antithrombin; false
LA feasible
inhibitors
Table has been adapted and updated from reference 4.

Table 3. Summary of Effects of Inappropriate Sample Processing Issues on Select Hemostasis Tests
Issue
Effect on Hemostasis Tests
Whole blood refrigerated

prior to centrifugation
Platelet activation and loss of FVIII and VWF; can lead to false diagnosis of
hemophilia or VWD
Filtered plasma
Loss of fibrinogen, FVIII, and VWF; can lead to false diagnosis of

dysfibrinogenemia, hypofibrinogenemia, hemophilia, or VWD; prolongs routine
coagulation test times (PT, APTT, and TT); false LA feasible
Delayed transport, delayed

testing, poor storage,
several freeze-thaw events;
storage in frost-free freezer
1. Loss of labile factors (especially FV and FVIII); can lead to false impression of
hemophilia; prolongs routine coagulation test times (PT, APTT); 2. Samples with
unfractionated heparin can yield lower than expected APTTs and lower anti-FXa
(heparin) test levels; 3. Potential activation of FVII
Poor centrifugation, heavy

braking, sample remixing
prior to freezing
Platelet contamination, hemolysis, and platelet disruption post freezing;

activation, false low APTT, false low heparin levels, false negative LA, false high
factor levels

Table 4. Summary of Misdiagnosis and/or Misidentification in Hemostasis Possibly Arising From Inappropriate
Sample Types
Misdiagnosis/Misidentification Can Arise From Testing Of
False-positive LA
Normal EDTA plasma, normal serum, vitamin K deficiency patient,

anticoagulated patient, heparin-contaminated sample, plasma containing
factor inhibitors
False diagnosis of VWD:
Filtered normal plasma, normal serum, normal plasma derived from

refrigerated whole blood sample
False subtype identification

(Type 2 diagnosis in Type 1
VWD patient)
Type 1 VWD plasma derived from refrigerated whole blood sample, testing of
filtered plasma or serum
False diagnosis of hemophilia A

refrigerated whole blood sample, aged sample, sample post several freezethaw events, heparin-contaminated sample, EDTA sample, normal serum
sample, underfilled primary citrate collection tube
False identification of factor

inhibitors
Heparinized normal sample, EDTA sample, normal serum sample, lupus

anticoagulant

To determine if the sample is serum, a TT can be performed. Non-clotting will suggest either serum or heparin
contamination, which can then be differentiated by mixing studies (ie, TT performed on sample mixed 1:1 with
normal plasma; if the mixed plasma clots, then serum is confirmed, whereas if the mixed plasma does not clot,
this would suggest heparin contamination). The presence of heparin can also be determined by use of a heparin
anti-FXa assay or by measuring a TT or APTT before and after the addition of a heparin-neutralizer. [37]
EDTA Plasma
This will raise coagulation test times such as PT and APTT and reduce FV and FVIII, leading to the potential false
identification of factor deficiencies and/or factor inhibitors. [35,36] If normal plasma mixing studies are performed on
EDTA plasma, lack of correction is seen, suggesting the presence of an inhibitor. In some cases it may also lead
to false identification of weak LA. As before, some test results might be normal (eg, VWF:Ag, D-dimer), and so,
the ability of a laboratory to recognize an EDTA plasma sample will depend on the tests performed. Assessment
of potassium (extremely increased) or calcium (very low to absent) will usually identify the presence of an
inappropriate EDTA collection. [37]
Heparin
Within a hospital setting heparin contamination is much more common than hemostasis assays incorrectly
collected in either EDTA or submitted as serum. Heparin is used as therapy for treating patients (eg, post
thrombosis), in "heparin flushes" to maintain flow in central lines, within "heparinized needles" (eg, blood gas
collection), and for many surgical applications. Effects on hemostasis tests depend on the heparin concentration
(or level of contamination) and the test performed. In general, clotting times (APTT and especially the TT) are
prolonged, and fibrinogen and clotting factors (especially APTT based, viz FVIII, FIX, FXI, FXII) reduced. [35,36] This
might lead to false identification of dysfibrinogenemia/hypofibrinogenemia and certain factor deficiencies. There is
also a potential for false identification of LA and factor inhibitors and reduced antithrombin. Sometimes, test
reagents (eg, for PT or LA detection) include heparin neutralizers, at levels sufficient to neutralize about 1 U/mL
unfractionated heparin. Although useful, this can lead to complex patterns of test results and laboratories are
sometimes falsely reassured that these tests are not influenced by heparin. Thus, a normal PT but abnormal
APTT, or an abnormal PT and APTT, can both arise, depending on the contaminating level of heparin and whether
the PT reagent contains heparin neutralizers. Results might be normal with some other tests (eg, D-dimer,
VWF:Ag), and so whether the laboratory recognizes a heparin-contaminated sample as such will again depend on
the tests performed.
Heparin contamination can be provisionally identified by testing of select clot-based assays (especially APTT and
TT), and then by mixing studies (see end of serum section above), and confirmed by using an anti-FXa assay or
by repeat APTT or TT testing after addition of a heparin neutralizer. [37]
Processing Issues
Badly processing samples can lead to hemolysis or platelet activation, falsely prolonging or shortened clotting
times, depending on the extent of hemolysis vs platelet activation. Alternatively, inadequate mixing may lead to
clotting or partial clotting and prolongation or shortening of clotting times and elevated or diminished clotting
levels. Freezing of plasma contaminated with cellular material may also lead to hemolysis or activation events, as
well as the potential for false-negative LA.
Hemolysis
This results from cellular destruction within whole blood and the release of cellular lysis products including
hemoglobin into the plasma. Although in vitro hemolysis might be a byproduct of a problematic collection or the
result of poor handling of blood post collection, hemolysis can also derive from in vivo blood cell lysis (eg, from
hereditary, acquired, and iatrogenic conditions such as autoimmune hemolytic anemia, severe infections,
intravascular disseminated coagulation, or transfusion reactions). [38] Hemolysis increases the spectrometric
absorbance of the plasma sample and leads to high background absorbance readings, which may compromise
clot detection by some instruments and thus affect the accuracy of test times. Instruments utilizing mechanical
means of clot detection are not affected by this interference, but the test result may still be compromised since
cell lysis products include tissue factors that may activate coagulation. The net effect is that detected fibrinogen
levels may fall with increasing hemolysis, whereas D-dimer levels may increase. Prothrombin time values may fall
in line with decreasing fibrinogen, whereas APTTs may increase or decrease depending on the net effect of
activation vs the loss of fibrinogen. Hemolysis may also influence other test results (eg, decrease antithrombin
levels).
If possible, grossly hemolyzed specimens should be rejected. If testing must be pursued (eg, if in vivo hemolysis
is present), testing using a mechanical end point detection system is recommended, although the potential effect
of activation should also be noted. Samples appearing hemolyzed due to the presence of a hemoglobin substitute
are not a cause of specimen rejection, and these samples should be evaluated using a mechanical or
electromechanical method for clot detection.
Hematocrit
The presence of significant anemia has not been shown to influence test results. [39] Too high a hematocrit will
influence the anticoagulant to plasma ratio and thus test results. [4,16] An adjustment in the ratio of anticoagulant
solution/volume of blood at different packed cell volume when hematocrit values are above 55% may be
undertaken using CLSI recommendations, although a simplified method is to remove 0.1 mL of sodium citrate
from a 5 mL 3.2% sodium citrate evacuated tube prior to collection. [40]
Lipemia
It is not easy to dichotomize the biological and analytical effect of lipemia on coagulation tests. [4,16] Acute
elevation of the coagulant activity of FVII is observed after consumption of high-fat meals, mostly due to an
increase in the concentration of activated FVII (FVIIa). High-fat meals also have a substantial, acute effect on
platelet function and may also induce a lowering of some clotting factor activities (eg, FII, FIX, FX, FVII, FVIIa,
FXIIa). Analytical interferences in some laboratory assays (especially those based on optical clot detection) also
occur but are minimized using mechanical or electromechanical-based procedures or using analyzers comparing
the absorption of samples at 2 wavelengths or performing coagulation assays at alternative wavelengths. [3,4]
Nevertheless, regardless of the potential source of interference (biological or analytical), the best approach might
be recollection of blood samples at fasting, provided that metabolic problems (ie, dyslipidemia) are absent.
Freeze-thawing Events
These result in the loss of some labile factors, notably FV and FVIII. Since it is not always clear how many times
a sample has been thawed and refrozen prior to testing, retesting using a fresh sample is always indicated should
an unexpected low factor result be obtained.
Under-recognized Pre-analytical Issues

Normal Reference Range Derivations and Related Issues
Laboratories use normal reference ranges (NRRs) to identify whether a test result is within the normal range or
outside this range (and to thus identify an abnormal result). Use of an inappropriate NRR may mean some normal
individuals will yield apparently abnormal test results. However, even the use of a typical and potentially
appropriate NRR, generated as the mean +/- 2 standard deviations, will identify 5% of the normal population as
outside this range, simply based on the statistical model used (ie, to capture 95% of the normal population).
Another way to consider this is to recognize that a standard laboratory NRR will correctly identify only 95 out of
every 100 normal test results. Put into clinical context, 5 in every 100 (or 1 in every 20) tests a clinician orders
(using such NRR estimates) will likely reflect a false abnormal test result, again simply based on the statistical
model used to generate the NRR. The relative false positive to true positive rate increases substantially for rare
disorders and is a particular problem with congenital disorders such as protein C, protein S, and antithrombin,
especially when patient cohorts are inappropriately selected for testing. [41,42]
Miscellaneous Variables
Age, gender, ethnicity, and blood group might influence reference values for certain parameters of laboratory
hemostasis, and/or generate variable test results for some tests. [4,43] For example, FVIII and VWF and platelet
function tests are generally influenced by such factors. Thus, interpretation of test results should consider these
issues to prevent misdiagnosis.
International Normalized Ratio (INR)
The INR is the most common test performed by coagulation laboratories. The INR derives as a mathematical
calculation, viz: INR=(patient PT/MNPT)ISI where MNPT=mean normal PT, and ISI=international sensitivity index.
The patient's PT is an analytical event and is derived from the instrument. However, the ISI and MNPT are derived
separately and might be considered as pre-analytical variables within the context of inaccurate INRs. [4,7]
Filtered Plasma
Plasma for LA testing must be essentially platelet free (<10 109/L) if frozen prior to testing. [4,16,30] Platelet-free
preparations can be achieved by a process of double centrifugation, high-speed (ultra-) centrifugation,
microfiltration, or combinations thereof; however, microfiltration, commonly used in the past because of its ease,
is no longer recommended. This is because the process leads to loss of other plasma components, including
FVIII and VWF, and may cause potential problems in LA detection because it artificially elevates the baseline
clotting times observed using some LA clot-based assays, and may also lead to a false conclusion of an elevated
APTT. In extreme cases, microfiltration may even generate false (weak) positive LA findings. Moreover, in many
routine hemostasis laboratories, LA testing is requested not only for specific investigation of APS but also for
investigation of unexplained prolongation of APTT test times, a common incidental finding in a laboratory practice.
The most common explanations are low levels of FXII or (unless the laboratory uses an LA-insensitive reagent) the
presence of (usually asymptomatic) LA. However, since an elevated APTT may also define a clinically significant
event, such as hemophilia or VWD, prolonged APTTs should be further investigated to determine the underlying
cause. It is therefore not uncommon to receive requests including test combinations for LA, and FVIII and/or VWF
to exclude LA, hemophilia or VWD, respectively. The dilemma is that should the laboratory process the sample
for LA testing by filtration, and then unwittingly test that sample for FVIII and VWF, a false diagnosis of hemophilia
or VWD is then quite feasible. Accordingly, the double centrifugation approach for preparation of hemostasis
samples prior to freezing is now strongly favored.
Physical Activity, Illness, and Stress
Excess physical activity in patients immediately prior to collection leads to certain in vivo events (eg, plasma
volume expansion and increased basal metabolism), which may in turn lead to significant effects on hemostasis.
However, perhaps the best-known acute effects are related to acute phase reactants, which may rise due to
physical activity, illness or stress, and include fibrinogen, VWF, and FVIII. In the worse case scenario, these
elevations may result in a misdiagnosis of (mild) hemophilia A or VWD Type 1 patients as a non-hemophilia or
non-VWD (false negatives). Blood collection may sometimes be stressful for some patients (particularly children)
leading to acute phase changes in proteins secondary to the phlebotomy itself.
Circadian and Diurnal Rhythms
Levels of some hemostasis components follow a circadian or diurnal rhythm, with differential levels detectable at
different times of the day. [4,44] For example, fibrinogen and plasminogen activator inhibitor-1 levels tend to be
higher in the early morning hours. PFA-100 closure times and possibly VWF may also provide different values
throughout a 24-hour period. Although most changes tend to be fairly subtle, in the worse case scenario this
might also lead to some clinically significant differences.
Patients on Anticoagulant Therapy
Testing for thrombophilia is often performed in patients who have recently suffered a thrombotic event. Patients are
placed on anticoagulant therapy after a thrombosis. Testing while on anticoagulant therapy will affect (both
biologically and analytically) many of the tests undertaken in this context, including LA, activated protein C
resistance (APCR), antithrombin, protein C, and protein S. Thus, false-positive and false-negative diagnoses can
both occur, depending on the extent of the anticoagulant effect, and the test performed. [41,42]
Other Medications That May Interfere With Coagulation Testing
A variety of therapeutic agents may cause spurious coagulation results due to variable mechanisms. This effect is
not always intuitive based on the pharmaceutical product. [4]
Clinical Ordering and Inappropriate Requests as a Pre-analytical Issue
The concept of clinical ordering patterns as a pre-analytical issue is also worth mentioning, in particular for the
case of inappropriate clinical orders. [4] There is heightened concern currently with respect to thrombophilia tests,
which comprise an area of investigation that is growing rapidly within hemostasis, and perhaps leading to "over" or
"inappropriate" ordering. [41,42] The proper timing of test orders is an important but poorly recognized issue.
Following a thrombotic event, some loss (consumption) of the natural anticoagulants might arise; hence, testing
too soon after a thrombosis might lead to false conclusion of a deficiency. FVIII may also be elevated post
thrombosis, leading to a missed LA diagnosis if only APTT-based screening tests are used. Alternatively,
anticoagulant therapy will affect the detected levels of the natural anticoagulants, as mentioned previously (viz,
heparin therapy may influence antithrombin detection, warfarin therapy may influence protein C and protein S
levels, and heparin and warfarin therapy may influence APCR testing). Heparin and warfarin therapy may also
influence the appropriate identification of LA. Recent audits of clinical practice indicate that up to 1/3 of samples
destined for thrombophilia investigations are from patients on warfarin and/or heparin therapy, or the sample is
otherwise heparin contaminated, and thus representing high potential for diagnostic error. Considered another
way, upwards of 80% of abnormal thrombophilia test results may be a reflection of inappropriate testing while on
anticoagulant therapy. [42]
Test Methodology and Test Panel Selection
While test results and methodologies comprise analytical issues, the choice of which particular methodologies or
test panels to use might best be considered as pre-analytical variables. The presence of LA or APCR, seen in
about 2%-5% of the general Caucasian population, may interfere with some clot-based protein C and protein S
assays, and lead to false identification of such deficiencies. [4] Insufficient laboratory test panels may also miss
significant disease. For example, VWD may be misdiagnosed or missed if the test panel does not include tests
for VWF activity, such as a collagen-binding assay. [45] Some methodologies are also poor at identifying low levels
of VWF, so type 3 VWD may be misidentified as type 1. In another example, different laboratories and even
experts use different tests (or methodologies) and test panels for the identification (or exclusion) of APS. [46]
Moreover, there are wide variations in the detection of solid phase aPL by different commercial assays, and
different perceptions will arise among practitioners regarding general sensitivities and specificities of different tests
and panels for APS, and different perceptions of positive or negative aPL for any given patient will arise among
clinicians, depending on both the methodologies, as well as the test panels, used to identify APS.
Conclusion
Pre-analytical issues in hemostasis testing are an important cause of diagnostic error (summarized in , and ) and
can lead to significant adverse clinical events. However, the burden of laboratory errors is estimated to remain
globally modest (ie, 1 in every 9002074 patients or every 2148316 laboratory results). [47] Notably, a large
number of errors are likely to be intercepted before they are released to the clinician and, thereby, before they
translate into real harm for the patient. The ultimate aim of laboratory practice would be to have no errors or to at
least detect and correct all errors before the test result is released. Accordingly, several tools might assist in their
identification, including a comprehensive education of all personnel regarding types and sources of errors, the
accurate evaluation of sample quality (ie, volume, blood to anticoagulant ratio, presence of potential interferents,
or contaminants), and the systematic recording of suspect results along with pertinent clinical information. [48]
When data are considered clinically questionable, the original test request should be checked and the specimen
inspected and retested, sometimes with different assays and instruments. The most reliable approach to deal with
laboratory errors is to establish a total quality management system. [4951] This would entail the elimination or
strict supervision of the most vulnerable activities, the implementation of customized for highlighting collection
requirements as related to specifically ordered tests, and facilitate the continuous education of operators (both
inside and outside the laboratory) by dissemination of best practice recommendations. [4951] This would include
providing adequate training and guidance to blood collectors.
Table 2. Summary of Differential Effects of Testing Different Sample Types on Select Hemostasis Tests
Potential
Sample Type
Routine Coagulation Tests
Consequences Potential Consequences On

On Factor
Other Hemostasis Tests
Assays
EDTA plasma
Prolongs PT and APTT, and

occasionally TT. Might influence
fibrinogen and D-dimer assays
False impression of inhibitors to

False low levels FV and FVIII, and may show
(especially FV time dependence (ie, enhanced
and FVIII)
with incubation); false LA
feasible
Serum or fully
clotted coagulation
sample
No fibrinogen, so no clot in PT, APTT,

or TT. False impression of
afibrinogenemia. D-dimer assays can
be affected especially if testing
delayed
False low levels

(especially FII,
inhibitors or VWD; false LA
FV, and FVIII);
feasible
false high FVII
Partially clotted
coagulation sample
Depending on relative extent of platelet

activation, hemolysis and loss of
False low factor
Flow obstructions in PFA-100
fibrinogen might lead to false
levels or false
testing
prolongation of PT, APTT, and TT, or
high factor VII
false shortening of APTT
Underfilled primary
Will typically prolong PT, APTT, and
citrate anticoagulant TT. May underestimate fibrinogen and
tube
D-dimer
False low factor False low levels of most

levels likely
hemostasis tests likely
Vitamin K-deficient
plasma, patient on
Prolongs PT and APTT (PT raised
vitamin K antagonist
>APTT raised)
therapy, liver
disease sample
False low
factors
(especially FII,
FVII, FIX, FX)
False low protein C (potentially

different effect with clot-based
assays vs chromogenic
assays); false low protein S;
false APCR; false LA feasible
Heparin
'contamination'
Prolongs PT, APTT, and TT (usually
(either ex-vivo or due TT raised >APTT raised >PT raised),
to collection tube
false low fibrinogen
error)
Reduced
factors
(especially
FVIII, FIX, FXI,
FXII)
False low Antithrombin; false

LA feasible
inhibitors

Table 3. Summary of Effects of Inappropriate Sample Processing Issues on Select Hemostasis Tests
Issue
Effect on Hemostasis Tests
Whole blood refrigerated

prior to centrifugation
Platelet activation and loss of FVIII and VWF; can lead to false diagnosis of
hemophilia or VWD
Filtered plasma
Loss of fibrinogen, FVIII, and VWF; can lead to false diagnosis of

dysfibrinogenemia, hypofibrinogenemia, hemophilia, or VWD; prolongs routine
coagulation test times (PT, APTT, and TT); false LA feasible
Delayed transport, delayed

testing, poor storage,
several freeze-thaw events;
storage in frost-free freezer
1. Loss of labile factors (especially FV and FVIII); can lead to false impression of
hemophilia; prolongs routine coagulation test times (PT, APTT); 2. Samples with
unfractionated heparin can yield lower than expected APTTs and lower anti-FXa
(heparin) test levels; 3. Potential activation of FVII
Poor centrifugation, heavy

braking, sample remixing
prior to freezing
Platelet contamination, hemolysis, and platelet disruption post freezing;

activation, false low APTT, false low heparin levels, false negative LA, false high
factor levels

Table 4. Summary of Misdiagnosis and/or Misidentification in Hemostasis Possibly Arising From Inappropriate
Sample Types
Misdiagnosis/Misidentification Can Arise From Testing Of
False-positive LA
Normal EDTA plasma, normal serum, vitamin K deficiency patient,

anticoagulated patient, heparin-contaminated sample, plasma containing
factor inhibitors
False diagnosis of VWD:

refrigerated whole blood sample
False subtype identification

(Type 2 diagnosis in Type 1
VWD patient)
Type 1 VWD plasma derived from refrigerated whole blood sample, testing of
filtered plasma or serum
False diagnosis of hemophilia A

refrigerated whole blood sample, aged sample, sample post several freezethaw events, heparin-contaminated sample, EDTA sample, normal serum
sample, underfilled primary citrate collection tube
False identification of factor

inhibitors
Heparinized normal sample, EDTA sample, normal serum sample, lupus

anticoagulant

Additional useful advice to laboratories and clinicians is be vigilant of all these issues; select/order the best tests
and test panels available, undertake testing only when necessary, at the correct point in time for the condition
under investigation; incorporate as much clinical information as possible into the diagnostic approach; follow the
recommendations of local laboratory experts/specialists; repeat tests when not in keeping with clinical
expectations or when an abnormal finding is reported; implement restrictive specimen acceptance policies and
tolerance criteria for inappropriate specimens; put quality practices into place where possible to aid in identifying
problem samples; and establish a mutually beneficial clinical-laboratory interface where both parties discuss the
problems within meetings or teaching moments as well as actively collaborate to achieve the best possible patient
outcome (). We also strongly recommend that laboratories use appropriate post-test guidance to assist clinicians
in the interpretation of test results, as well as to guide when repeat, confirmatory, and follow-up testing may be
required. [4,52]
Table 5. Important Issues for Laboratories and Clinicians to Consider Within the Context of Pre-analytical Issues in
Hemostasis Testing, and Some Recommendations
Issue
Consideration/Recommendation
Test selection
Select/order the best tests/test processes/test panels for the

condition being investigated
Population to be tested and clinical

condition/medication at time of testing
Select the appropriate population/methodology to determine the

normal reference range
Only order the test(s) when clinically appropriate and in the right
patient at the right time
Sample collection
Proper patient and sample identification

Atraumatic phlebotomy with minimal tourniquet use
Draw blue stopper tube (citrate anticoagulant) first or only after a nonadditive tube
Fill tube adequately (no less than 90% fill)
Adequately and thoroughly mix with tube anticoagulant

Sample transport
Transport promptly at room temperature
Sample processing
Ideally centrifuge within 1 hour of phlebotomy to obtain platelet-poor

plasma (most tests)
Double centrifuge plasma for some tests, namely LA, APCR, and
heparin (anti-Xa) assays
Aliquot (in a non-activating secondary tube) immediately following
centrifugation for those tests to be performed later
Special requirements for some tests such as platelet function and
PFA-100
Sample storage
Test plasma within appropriate timeframe; store as required samples

to be tested subsequently
Sample testing
Select the best test/methodology/test panel for the analyte/parameter

being tested
Perform test in timely manner and according to best practice
Result interpretation
Laboratory: Provide clinician with appropriate guidance/test

interpretation
Clinician: Recognize test limitations/extra-analytical issues that may
influence test results and follow local expert laboratory advice

There have been several new oral anticoagulants recently released onto the market (most notably Dabigatran and
Rivaroxaban) for a variety of clinical indications including prevention of venous thromboembolism after major
orthopaedic surgery or secondary prevention in atrial fibrillation. These agents will variously affect coagulation and
hemostasis tests as described elsewhere, [53,54] but should now also be considered within the context of
preanalytical problems associated with hemostasis testing.
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Abbreviations
LA, lupus anticoagulant; APS, antiphospholipid (antibody) syndrome; VWD, von Willebrand disease; VWF, von
Willebrand factor; PT, prothrombin time; INR, international normalized ratio; APTT, activated partial thromboplastin
time; TT, thrombin time; DIC, disseminated intravascular coagulation; F, factors; CLSI, Clinical and Laboratory
Standards Institute; ISI, international sensitivity index; EDTA, ethylenediaminetetraacetic acid; aPL,
antiphospholipid; aCL, anticardiolipin; aB2GPI, anti-beta-2-glycoprotein I; NRR, normal reference range; MNPT,
mean normal PT; APCR, activated protein C resistance
Lab Med. 2012;43(2):1-10. 2012 American Society for Clinical Pathology
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Pre-Analytical Variables in Coagulation Testing

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Pre-analytical Variables in Coagulation Testing

Abstract and Introduction

Consequences of Pre-analytical Issues

Overview of Hemostasis, Laboratory Testing, and Pre-analytical Issues

Usually Performed Via

Citrate anticoagulated plasma post single

A. Routine coagulation tests

PT/INR, APTT, TT, fibrinogen

Clot-based tests, automated

Clot-based tests, automated

Separated citrate anticoagulated plasma, post

ELISA, immunoassay, clot

Heparin (anti-Xa) assay

Clot-based tests, automated

Clot-based tests, automated

Separated citrate anticoagulated plasma, post

Solid phase aPL tests

Separated serum preferred; separated citrate

Platelet function tests

Citrate anticoagulated whole blood or special

Genetic thrombophilia tests

EDTA or citrate anticoagulated whole blood or

Table 1. Summary of Hemostasis Tests and Sample Requirements

Usually Performed Via

Citrate anticoagulated plasma post single

A. Routine coagulation tests

PT/INR, APTT, TT, fibrinogen

Clot-based tests, automated

Clot-based tests, automated

ELISA, immunoassay, clot

Heparin (anti-Xa) assay

Separated citrate anticoagulated plasma, post

Separated citrate anticoagulated plasma, post

Clot-based tests, automated

Clot-based tests, automated

Separated citrate anticoagulated plasma, post

Solid phase aPL tests

Separated serum preferred; separated citrate

Platelet function tests

Citrate anticoagulated whole blood or special

Genetic thrombophilia tests

EDTA or citrate anticoagulated whole blood or

Appropriate Sample Collection, Processing, and Storage

Sample Processing and Storage

Usually Performed Via

Citrate anticoagulated plasma post single

A. Routine coagulation tests

PT/INR, APTT, TT, fibrinogen

Clot-based tests, automated

Clot-based tests, automated

ELISA, immunoassay, clot

Heparin (anti-Xa) assay

Clot-based tests, automated

Clot-based tests, automated

Separated citrate anticoagulated plasma, post

Solid phase aPL tests

Separated serum preferred; separated citrate

Separated citrate anticoagulated plasma, post

Separated citrate anticoagulated plasma, post

including aCL and ab2GPI

centrifugation sometimes acceptable. Usually

Platelet function tests