COAGULATION AND

HEMOSTASIS

HEMOSTASIS
PURPOSE
Ensure that coagulation mechanisms are
activated when there is injury
not unnecessarily activated

Restore tissue blood fl ow after repair of

injury (fi brinolysis)

HEMOSTATIC PROCESS
3 main steps

Primary hemostasis: local

vasoconstriction & platelet plug
formation
Coagulation cascade
Fibrinolysis

HEMOSTATIC PROCESS

PLATELET PLUG FORMATION

vascular injury

release and binding of vWF to exposed

blood vessel collagen
glycoprotein IB on platelet surface
membrane binds to vWF
TxA 2 vasoconstriction & platelet
adhesion

PLATELET ACTIVATION &

AGGREGATION
exposed endothelial surface
platelets exposed to collagen
activated
release contents of cytoplasmic granules

adenosine diphosphate (ADP)

accelerates platelet
aggregation/activation
platelets

thromboxane (Tx A 2 )

vasoconstriction
ADP release from

HEMOSTATIC PROCESS

COAGULATION CASCADE
to stabilize and reinforce the weak
platelet plug
fi brinogen fi brin
3 main steps:
1.

formation of prothrombin activator

2.

conversion of prothrombin into thrombin

3.

conversion of fi brinogen to fi brin

COAGUL ATION CASCADE

TF =tissue factor
PK = prekallikrein
HK=high
molecular
kininogen
a = activated

COAGULATION MECHANISM
activation of clotting factors
requires a phospholipid surface
tissue factor (TF) extrinsic to the blood
activated platelet (platelet factor 3 phospholipid) intrinsic to
blood

vitamin-K dependent factors (II, VII, IX, X)

formation of reaction complex
labile factors : factors V and VIII

Intrinsic pathway

Extrinsic pathway
TF

XII
XIIa
Contact Factors
XI

VIIa

XIa

thrombin

VII

..

Ca++

TF+VIIa
Ca++/PL

IX

IXa

Ca++/PL-

VIII thrombin

VIIIa

tenase
Xa

X
V

thrombin

Va

Ca++/PL-

prothrombinase
XII

Prothrombin (II)

Thrombin (IIa)
XIIa

Fibrinogen

Fibrin

cross-linked fibrin

2 main functions of tissue factor (TF)

1) to activate factor X to Xa
2) to activate factor IX to IXa

Platelet activation
Fibrinogen to fibrin
Factor XIII to XIIIa

thrombin

Factor XI

to

FXa

Factor V
Factor VIII

Va
VIIIa

FIBRINOLYSIS

Plasminogen plasmin

Release of tPA by the endothelium

Lysis of clot FDPs or FSPs
Reopening of blood vessel

L ABORATORY MONITORING

ACTIVATED PARTIAL PROTHROMBIN

TIME (APTT)
PRINCIPLE:
This is a non-specifi c test of the intrinsic
system. Taken in conjunction with a
normal prothrombin time, it is the most
useful screening test for detecting
defi ciencies of factors VIII, IX, XI, and XII.
Normal value: 25s -35s

LABORATORY MONITORING

ACTIVATED PARTIAL PROTHROMBIN

TIME (APTT)
METHOD:
Place tube containing calcium chloride at 37C
for fi ve minutes prior to use.
Pipette 0.1 ml of APTT reagent into two glass
clotting tubes at 37C.
Pipette 0.1 ml control plasma into fi rst tube.
Start master stopwatch. Mix.
Add 0.1 ml control plasma to second tube. Mix.
After recommended incubation time, add 0.1 ml
calcium chloride to each tube in succession,
starting a new stopwatch for each tube. Mix.
Time clot formation.

LABORATORY MONITORING

PROTHROMBIN TIME (PT)

PRINCIPLE:
This test refl ects the overall effi ciency of the
extrinsic system. It is sensitive to changes in
factors V, VII, and X, and less so to factor II
(prothrombin). It is also unsuitable for detecting
minor changes in fi brinogen level, but may be
abnormal if the fi brinogen level is very low or if
an inhibitor is present. The sensitivity of the
test is infl uenced by the reagent and technique
used, and it is important to establish a
reference range locally.
Normal value: 10-30s

LABORATORY MONITORING

PROTHROMBIN TIME (PT)

METHOD:
To the fi rst two tubes, add 0.1 ml normal plasma
and warm to 37C for 2 minutes.
Add 0.2 ml pre-warmed (to 37C)
thromboplastin reagent (if calcium is present in
the reagent).
Start stopwatch, mix, and record clotting times.
Repeat for each test sample.
Report patients clotting time in seconds.

LABORATORY MONITORING

INTERNATIONAL NORMALIZED RATIO

PRINCIPLE:
International normalized ratio (INR) is a
calculation made to standardize prothrombin
time. INR is based on the ratio of the patient's
prothrombin time and the normal mean
prothrombin time.

LABORATORY MONITORING

INTERNATIONAL NORMALIZED RATIO

LABORATORY MONITORING

THROMBIN CLOTTING TIME (TCT)

PRINCIPLE:
The thrombin time reflects the reaction between
thrombin and fi brinogen.
Thrombin
Fibrinogen Fibrin
Normal value: 17-25s

LABORATORY MONITORING

THROMBIN CLOTTING TIME (TCT)

METHOD:
Into a glass clotting tube, pipette 0.2 ml
plasma.
Warm to 37C.
Add 0.2 ml thrombin.
Start stopwatch. Time clot.
A normal range should be established
locally.
Test in duplicate.

LABORATORY

COMPONENTS
MEASURED

TEST
Bleeding time

platelet function
vascular integrity

NORMAL
VALUES
3 - 10
mins

PT

I, II, V, VII, IX, X

10 - 13
secs

PTT

I, II, V, VIII, IX, X, XI, XII

25 - 35
secs

Thrombin time

I, II

17 - 25
secs

DRUGS AFFECTING
COAGULATION
HEMOSTATIC
PROCESS
AFFECTED

CLASS OF
DRUGS

SPECIFIC
DRUGS

1 platelet plug
antiplatelet drugs
formation inhibition

reversible: NSAID

coagulation
cascade

standard and LMW

heparins
warfarin

IV anticoagulants
oral anticoagulants

fibrinolysis

fibrinolytic agents

Streptokinase
Urokinase
t-PA

PROSTAGLANDIN SYNTHESIS
arachidonic acid
cyclooxygenase

prostaglandin G 2
peroxidase

prostaglandin H 2
prostacyclin
synthetase

prostacyclin
PG F 1 a

thromboxane
synthetase

thromboxane A 2
thromboxane B 2

MECHANISM OF ACTION

ASPIRIN
arachidonic acid

ASPIRIN

cyclooxygenase

prostaglandin G 2
peroxidase

prostaglandin H 2
prostacyclin
synthetase

prostacyclin
PG F 1 a

thromboxane
synthetase

thromboxane A2
thromboxane B2

MECHANISM OF ACTION

ASPIRIN AND NSAIDS

arachidonic acid

ASPIRIN

cyclooxygenase

prostaglandin G 2

NSAIDS

peroxidase

prostaglandin H 2
prostacyclin
synthetase

prostacyclin
PG F 1 a

thromboxane
synthetase

thromboxane A2
thromboxane B2