bleeding time and clotting time are important tests done to detect the disorders related to haemostasis

1. BLEEDINGTIME
&
CLOTTINGTIME
MithunVenugopal. A
Haematology &Transfusion Medicine

2. TESTS FOR
HAEMOSTASIS
AND
COAGULATION
1. TESTS FOR VASCULAR COMPONENET
a) Capillary fragility test
b) Bleeding Time (BT)
2. TESTS FOR PLATELET COMPONENET
a) Platelet count
b) Platelet adhesion test
c) Platelet aggregation test
d) Clot retraction test
2

3. 3. TESTS FOR COAGULATION FACTORS
a) Clotting Time (CT)
b) Prothrombin Time (PT)
c) Activated Partial Thromboplastin Time (APTT)
d) Thrombin Time (TT)
e) Factor XIII screening
f) Specific tests- factor assays, mixing studies
4. TESTS FOR FIBRINOLYSIS
a) Whole blood clot lysis test
b) Euglobulin lysis test
c) FDP and D-Dimer
3
TESTS FOR
HAEMOSTASIS
AND
COAGULATION

4. BLEEDING
TIME
First functional platelet evaluation test.
Introduced by duke in 1900.
Used to detect defects in primary hemostasis.
Used as a screening test for vascular disorders as
well as platelet disorders.
4

5. Bleeding time is defined as the time taken for a
standard skin wound to stop bleeding ,upon vessel
injury , platelets adhere and form a haemostatic
platelet plug.
Bleeding time measures the ability of the platelets
to arrest bleeding and therefore measures platelet
number and function.
5
BLEEDING
TIME

6. PRINCIPLE
A standardised incision is made on the volar surface of
the forearm.
The time the incision bleeds is recorded.
Cessation of bleeding indicate the formation of
hemostatic plug.
Depends on the adequate number of platelets and on
the ability of the platelets to adhere to the
subendothelium.
6

7. METHODS
1. Duke’s Method
2. Ivy’s Method
3. StandardTemplate Method
7

8. IVY’S
METHOD
REQUIREMENTS:
BP cuff
Disposable lancet
Stop watch
Filter paper
Spirit/alcohol
8

9. PROCEDURE
Clean the inner aspect of the fore arm.
Place a BP cuff on the upper arm , inflate to 40 mm of
mercury.
Select an area on the volar surface which is devoid of
veins.
Should be performed at room temperature.
A disposable lancet with a point of about 3mm /No.11
bard parker surgical blade is used.
9

10. PROCEDURE
Two skin punctures 3mm deep is made.
Stopwatch is started as soon as the bleeding starts in
each wound.
Using the edge of a filter paper (Whatman No:1) , blot
the blood accumulated over the wound without
touching the wound.
The time from which incision was made to the time at
which the bleeding stops to stain the filter paper is
taken.
10

11. PROCEDURE
The average of the 2 bleeding time is taken.
The BP cuff is removed.
The puncture wounds are cleaned.
Sterile bandage is applied.
Longer bleeding time-puncture of superficial veins.
11

12. PROCEDURE
If bleeding continues more than 15 min-apply pressure
Repeat the bleeding time on other arm.
Report-greater than 15 min.
Reports correlated with platelet count.
Reference range: 2-7 minutes.
12

13. ADVANTAGE
Standardized method.
More accurate.
13

14. LIMITATIONS
Not a very reliable test.
The puncture wound may close before the cessation of
bleeding.
14

15. STANDARD
TEMPLATE
METHOD
More standardized method.
Uses a glass or plastic template.
Allows the lancet to make a cut-11 mm long and
1mm deep.
15

16. PROCEDURE
16

17. PROCEDURE
17

18. PROCEDURE
18

19. ADVANTAGES
Test is very sensitive and reproducible.
Detects even minor alterations in platelet function.
19

20. DUKE’S
METHOD
Easy to perform
Requires minimal equipment
Requirements:
Alcohol
Sterile lancet
Stopwatch
Filter paper
20

21. PROCEDURE
Clean the finger tip with alcohol sponge.
Infants-heel of foot.
Make a deep puncture with sterile lancet.
Start the stop watch.
Using filter paper blot the drop of blood coming out
from incision.
21

22. PROCEDURE
When bleeding ceases stop the stop watch.
Count the number of drop on the filter paper.
Multiply by 30 sec.
Report the closest minute.
If the cut bleeds more than 10 minutes, discontinue
the test.
22

23. ADVANTAGE
&
DISADVANTAGE
ADVANTAGE:
The ear lobule contain abundant
subcutaneous tissue and is
vascular.
Flow of the blood is quite good.
Normal bleeding time-3-5
minute.
DISADVANTAGE:
Difficult to get a standardized
wound.
23

24. VARIABLES
AFFECTING
BLEEDING
TIME
Patients with thrombocytopenia(<100×109 /L) Will
have increased BT.
Aspirin, penicillin, cephalothin prolongs BT.
Pediatric patients and neonates –smaller incisions
are required. pressure -20 mm of Hg.
Anemia prolongs the bleeding time.
24

25. CLINICAL
SIGNIFICANCE
Prolonged BT is seen in:
Thrombocytopenia
Glanzmann's thrombasthenia
Storage pool disease
Bernard – Soulier syndrome
Afibrinogenemia
Severe hypofibrinogenemia
Vascular disorders
Aspirin
25

26. CLINICAL
SIGNIFICANCE
Aplastic anemia
A/c leukemia
Liver diseases
VonWillebrand disease
DIC
Vascular abnormalities -Ehlers Danlos syndrome
Severe deficiency of factorV or XI
26

27. CLOTTING
TIME
27

28. CLOTTING
TIME
The time taken for whole blood, drawn from a vein
and immediately placed in a container to clot.
It measures all stages of intrinsic coagulation.
It is not a very sensitive method.
Avoid contamination with tissue fluid.
28

29. METHODS
1. Modified Lee and White Method
(Venipuncture Method)
2. Capillary Method
29

30. LeeandWhite
Method
REQUIREMENTS:
Cotton wool, surgical gauze soaked in alcohol,
plastic syringe
Test tube-acid washed(10ml)
Water bath -370 c
Stop watch
30

31. TWO SYRINGETECHNIQUE-avoid interference of
tissue fluid.
Draw 1 ml of blood into first syringe.
Without disturbing the position of the needle 2nd
syringe is attached and 5ml of blood is drawn.
31
SAMPLE
COLLECTION

32. Draw 3 ml of venous blood with aseptic
precautions.
Label 3 test tubes as No. 1, 2, 3 and keep in a water
bath at 37oc .
Deliver 1 ml of blood into each of the above 3 test
tubes and start the stop watch.
After 3 min, take out tube No 1 , tilt it every 30
seconds till a clot develops.
32
PROCEDURE

33. PROCEDURE
Note the time when the tube can be inverted
completely.
Next examine the No 2 every 30 seconds , exactly
the same way as tube No 1, till the clot forms and
note the time.
Finally, invert the third test tube as above till the
blood clots. Stop the watch.
Record the time from the moment blood is
delivered in to the test tube to the complete
clotting in the third tube.
The clotting time of the third tube is reported as
the clotting time.
33

34. PROCEDURE
34

35. ADVANTAGE
&
DISADVANTAGE
ADVANTAGE:
standard method
Test can be run with control
DISADVANTAGE:
Not a sensitive test
Only a rough method
There can be contamination of syringe /tubes
35

36. NORMAL
VALUE
Normal value-4-11 ‘ min
36

37. SOURCES
OF ERROR
Faulty technique
Inappropriate volume of blood
Faulty venipuncture
Air bubble entering the syringe
Diameter of the glass tube should be uniform
Always use clean glass wares and plastic syringe
Vigorous agitation should be avoided.
37

38. CAPILLARY
METHOD
REQUIREMENTS:
Disposable lancet
Capillary tubing10-15 cm length and 1.5 mm
diameter without anticoagulant
Alcohol swab
Cotton
Stop Watch
PPE’s
38

39. CAPILLARY
METHOD
PRINCIPLE:
Puncture the skin, blood is taken to a plain capillary
tube and stop watch started.
Formation of fibrin strings is noted by breaking the
capillary tube at regular intervals.
The time taken for the first appearance of the fibrin
string is noted.
39

40. PROCEDURE
Warm up the finger for skin puncture.
Make an incision with a sterile disposable lancet to
depth of 3mm.
As soon as blood is visible- start the stop watch.
Wipe off the first drop of blood.
Allow 2nd drop of blood to flow to capillary tube.
40

41. After 2’ break off the capillary tubing,1-2 cm from
the end.
When a thin string of fibrin can be seen in between
the broken end of the capillary tube, stop the watch
and note the time.
Report the time.
41
PROCEDURE

42. 42
PROCEDURE

43. ADVANTAGE
&
DISADVANTAGE
DISADVANTAGE:
This method is insensitive
This method is unreliable
Capillary blood always contaminated with tissue
fluid
ADVANTAGE:
Can be performed when venous blood cannot be
obtained
NORMAL VALUE: 1-5 min
43

44. CLINICAL
SIGNIFICANCE
Prolonged clotting time seen in deficiency states
involving ,Plasma thromboplastin component,
plasma thromboplastin activator.
Also prolonged in pt with bone marrow depression
and thrombocytopenia.
Deficiency of FV,VII, and X, fibrinogen, Liver
diseases.
44

45. THANK
YOU
45