Stago EdVantage Virtual University

Laboratory monitoring of oral and parenteral anticoagulants plays a key role in ensuring their safe and effective use.  Laboratory personnel play an essential role in ensuring appropriate use and interpretation of these lab tests. This webinar will focus on the monitoring of unfractionated heparin and the newer direct oral anticoagulants, focusing on anti-factor Xa testing.

• Describe the advantages and disadvantages of using the activated partial thromboplastin time (aPTT) versus an anti-factor Xa assay to monitor the effects of unfractionated heparin.
• Recommend appropriate laboratory testing to assess coagulation status in patients taking a direct oral anticoagulant (DOAC).
• Discuss the role of anti-factor Xa assays in monitoring oral and parenteral anticoagulants.

Lupus anticoagulants are markers of prothrombotic potential which may be indicative of underlying antiphospholipid syndrome (aPS) requiring treatment with ongoing anticoagulants.  The purpose of this educational program is to update healthcare professionals regarding advancements in Lupus Anticoagulant (LA) testing. Current LA diagnostic guidelines, clinical evidence regarding LA significance, assay selection, and anticoagulant drugs interfering with LA testing will be discussed, along with clinical cases of high interest.

• Describe role of Lupus Anticoagulant (LA) in Antiphospholipid Syndrome (APS).
• Define current ISTH and CLSI Guidelines, identify tests, and define patient selection for appropriate LA work up.
• Recognize medications that may cause false positive LA results.
• Evaluate the right testing strategy for LA testing.
• Correlate LA and APS to specific clinical cases.

This webinar will look at the principles of the assays available to monitor heparin.  The most frequent assay that is used is the activated partial thromboplastin time (aPTT).  This assay is readily available and inexpensive.  However aPTT reagents are poorly standardized and have different sensitivities to heparin. There is no dose response relationship with heparin.  Due to the analytical and biological variables of heparin, patients respond to it differently.  Laboratories using the aPTT to monitor heparin, need to provide clinicians with a heparin therapeutic range specific for their lot of reagent on their analyzer.  An anti-Xa assay is a standardized test that has good precision, and is linear. A heparin assay can provide clinicians with an assay that accurately determines heparin levels and can improve overall patient heparin management.

The objectives of this webinar are:

• Describe the principle of the aPTT and  heparin assays
• Identify the advantages of each assay and outcomes for patient care
• Enhance problem solving skills by analyzing data from case studies.

When patients taking direct oral anticoagulants (DOAC's) are admitted to the hospital, there may be a need for bridging parental anticoagulation especially for those at high risk of thrombosis recurrence.  By presenting information on DOAC interference in laboratory assays, institutional experiance, and case studies, this webinar will address questions surrounding management of patients on DOAC therapy.

Objectives:

• Identify the effects of direct oral anticoagulants on common  and other anticoagulation laboratory measures
• Describe common errors that are seen in practice when the effect of DOACs on common anticoagulation laboratory measures is not realized
• When presented with challenging cases, show how traditional and other laboratory measures can help guide safe, appropriate therapy

Hemostasis testing quality is determined by preanalytical variables which encompass patient preparation, sample collection, handling, transportation, processing and storage.  If any of the preanalytical variables are not properly adhered to, incorrect or uninterpretable results are reported resulting in possible adverse patient consequences or delays in treatment.  This webinar will provide background on commonly performed coagulation screening tests but also discuss the impact of preanalytical variables on these tests.

Coagulation testing methodologies are often challenging for new users to understand.  Terminology may be confusing and the methodologies are sensitive to many variables.  Consideration of biological, preanalytical, and analytical conditions is critical to reporting accurate results.  This webinar will be focused on explaining methodologies, including tests used to screen for bleeding and thrombotic disease states, determining coagulation factor levels, confirming the presence of lupus anticoagulants, and tests utilized to diagnose von Willebrand Disease.  In addition, platelet function testing and global hemostasis assays will be briefly covered.

Learning objectives:

• Review hemostasis-related laboratory studies, including coagulation testing, von Willebrand factor assays, and platelet studies
• Present all relevant terminology, methodologies, test selection, test performance sequence, and interpretation
• Discuss use of laboratory testing to evaluate a range of bleeding disorders

According to the National Trauma Institute, trauma accounts for 41 million emergency room visits and 2.3 million hospital admissions annually in the US, resulting in an overall annual economic burden of $671 billion in healthcare costs and productivity losses.  Coagulation testing is often required to identify acute trauma-induced coagulopathy and guide treatment for bleeding and related disorders for optimal outcomes.  This educational presentation will outline the clinical issues along with up-to-date diagnostic and treatment practices, enabling participants to implement these practices in their local settings.

Learning Objectives:

1. Review incidence, clinical diagnostic algorithms and treatment strategies for patients presenting to the emergency department with trauma induced coagulopathy
2. Discuss coagulation testing panel selection for trauma patients
3. Highlight case studies and outcomes for patients diagnosed and treated with trauma-induced coagulopathy

This session will look at the common issues that can impact quality in the coagulation laboratory and result outcomes.  Implementing a good quality management system and being able to conduct a root cause analysis can not only solve problems, but can help to establish protocols that will prevent them in the future. Information will be presented in a case study format to highlight real-life case scenarios and how laboratories can handle and prevent future issues to ensure they can optimize their coagulation testing and patient care.

Objectives:

• Identify solutions in areas of coagulation that can be enhanced by implementing good laboratory practices and standard operating procedures
• Analyze real-life case studies and how to troubleshoot testing to determine root cause and steps to prevent reoccurrence.
• Enhance general knowledge of coagulation standards and methods

Laboratory testing for coagulation factor deficiencies and inhibitors is important for diagnosing and monitoring inherited and acquired coagulopathies and for evaluating the causes of coagulation screening test abnormalities. The webinar will cover strategies and pitfalls to consider and which assays should be performed to further evaluate test abnormalities, including assays for specific factor inhibitors. Real life cases, and illustrations of pre-analytical errors and interferences, will be used to illustrate important practice points. The different patterns and causes of abnormalities will be reviewed to ensure that laboratories consider all potential causes of abnormal findings.

Participants in this session will be able to:

• Differentiate which factor deficiencies are common and which are rare
• Describe what factor assays should be considered for a preoperative patient with a prolonged APTT, and which abnormalities are most common
• Describe how to test for a coagulation factor deficiency and a specific factor inhibitor
• Describe at least two pre-analytical errors that could cause test abnormalities that mimic a factor deficiency

Despite the development of new anticoagulants, unfractionated heparin (UFH) continues to be a primary choice for intravenous anticoagulant therapy because of its titratability, short half-life, ability to use in patients with renal failure, and acute reversibility. UFH continues to be the mainstay of parenteral anticoagulation especially in critically ill patients and to maintain anticoagulation during mechanical cardiopulmonary support.  As with all intravenous anticoagulants, monitoring is required for its use. In critically ill patients, UFH can be monitored by multiple tests that include the activated partial thromboplastin time (aPTT), heparin activity measured by antifactor Xa (anti-Xa), or activated clotting time (ACT). Although the aPTT and the ACT are frequently used for monitoring, there are multiple limitations. Anti-Xa heparin monitoring represents an important alternative, and I routinely used anti-Xa monitoring as our standard of measurement in my previous institution. However, aPTT is the standard for monitoring in my current institution.  Despite this, I frequently use anti-Xa monitoring as an important guide to therapy especially in critically ill, complex patients especially during ECMO and mechanical cardiopulmonary support. Anti-Xa monitoring is a more direct measure of UFH activity than the aPTT, demonstrates less variability and is most helpful when conflicting values occur during aPTT monitoring.  In this presentation, I will review UFH monitoring focusing on the use of the anti-Xa for critically ill and general patient management.

Learning Objectives

• Summarize different methods for heparin monitoring in the ICU and hospital
• Describe limitations and benefits of different testing focusing on anti-Xa monitoring
• Discuss the role of anti-Xa monitoring and clinical applications in critically ill patients

Antiphospholipid syndrome (APS) is an autoimmune acquired thrombophilic disorder which is diagnosed based on clinical and laboratory criteria; of the laboratory criteria, a positive lupus anticoagulant (LA) is one of the best predictors of thrombotic risk in APS.

Laboratory testing for APS, as well as the accurate reporting of the data, is complicated and is governed by multiple guidelines from national and international organizations. Given that LA testing is clot-based, anticoagulants and factor deficiencies can significantly interfere with accurate testing; the choice of LA testing reagents can help limit the impact of these interferences. One laboratory's experience optimizing LA testing and APS reporting will be discussed, with interesting cases reviewed.

Learning Objectives:

• Review international guidelines for antiphospholipid syndrome (APS) laboratory diagnosis and reporting
• Examine lupus anticoagulant biochemistry
• Share our laboratory’s improvements in our APS testing reagents, workflow, and turn-around time of comprehensive APS reports
• Learn from some interesting APS cases showing common and rare LA interferences

D-dimer can be a useful tool in the management of patients with suspected or established venous thromboembolism (VTE). One use is in the assessment of a patient who presents with symptoms of VTE. First, a pre-test probability assessment with a validated scoring system, such as the Wells’ score, is performed by the clinician. Based on the absence or presence of a number of symptoms and signs of VTE and the presence of VTE risk factors, a patient is considered to be at low or high risk for VTE. In the low risk group, a D-dimer can then be performed. A negative result rules out VTE, making further imaging studies (e.g. venous Doppler ultrasound or chest CT scan) unnecessary. The second use of the D-dimer test is as a tool when determining the length of anticoagulation therapy necessary in a patient who has had a VTE. In patients with unprovoked or estrogen-associated VTE, a negative D-dimer – on or off anticoagulation - predicts a lower risk of recurrence, whereas a positive D-dimer predicts a higher risk. D-dimer has been incorporated into several decision tools for assessing length of anticoagulation, such as the HERDOO-2 score, the DASH-score, and the Vienna-score.

Learning Objectives:

• Discuss how D-dimer is used by clinicians in conjunction with a clinical pre-test probability assessment in the evaluation of a patient who presents with symptoms leading to suspicion of deep vein thrombosis (DVT) or pulmonary embolism (PE)
• List several of the components of the Wells’ score for the pretest probability assessment of DVT and PE
• Discuss how  D-dimer is used by clinicians to determine length of anticoagulation in patients with DVT or PE
• Discuss the risk-of-VTE-recurrence triangle and VTE recurrence risk assessment tools (e.g. HERDOO-2 score, DASH-score, Vienna score) available to clinicians for determining how long a patient should be treated with anticoagulation

Coagulation testing is commonly performed in hospital systems to screen for potential bleeding or thrombotic disorders. Examples of patient populations and clinical applications include outpatients presenting to the emergency room with signs of venous thromboembolism (VTE), perioperative screening to exclude the potential for bleeding during surgery, or to monitor inpatient anticoagulant treatment. Newly acquired coagulation testing instruments require an extensive validation process before being used for live patient testing in order to ensure quality of test results. Instrument validation can be especially challenging for different hospitals within a health network, due to different testing menus, volumes, and instruments used in these centers. The webinar will provide guidance on how coagulation testing instruments are validated, test results verified, and ensuring continuous quality during the life of the instruments.

Learning objectives:

• Describe the responsibility of the laboratory during the validation process of new instrumentation 
• Distinguish between validation and verification of laboratory instrumentation
• Present strategies for ensuring continuous quality of laboratory testing results on a daily basis, focusing on hemostasis testing

Have you ever wondered about the impact of direct oral anticoagulants (DOACs) on routine coagulation assays and how patients on DOACs can be managed by the clinical laboratory? DOACs have been available for several years to treat atrial fibrillation patients at risk of stroke, as well as patients with venous thromboembolism (VTE). Though routine monitoring is not required for patients taking DOACs, screening or measurement assays could help in some emergency patient management situations. Dr Crowther’s webinar will cover this hot topic, which regularly impacts patients in critical care settings.

Learning objectives:

• Highlight recent clinical trials describing use of DOACs
• Present situations for which DOAC monitoring can help in the picture of patient care
• Review best practice with respect to DOAC measurement

Case studies to practice problem solving in the coagulation laboratory will be presented during this webinar. It will review pre-analytical issues impacting results as well as testing patterns that can be both cost effective while optimizing patient outcomes. Coagulation disorders and dedicated assays can be complex for newcomers and the best results are obtained when testing is approached in a logical, step by step manner. Understanding the importance of accurate screening results in the diagnosis and management of patients will only improve the information the laboratory provides to clinicians.

Learning objectives:

•  Identify proper testing to aid in the diagnosis of bleeding or clotting disorders
•  Perform best coagulation practices to help maximize negative outcomes while minimizing costs
•  Enhance problem solving skills by presentation of applicable case studies

D-dimer is used in the clinical evaluation of suspected venous thromboembolism (VTE). Newer measurement methods show high sensitivity for this test, and in combination with pretest probability assessment, have a high negative predictive value for exclusion of VTE, obviating the need for many imaging procedures, optimizing healthcare resource utilization. This presentation will highlight the evidence supporting the clinical utility of D-dimer in VTE: upper extremity, lower extremity, recurrent lower extremity DVT and pulmonary embolism. The American Society of Hematology 2018 updated clinical practice guidelines outlining an evidence-based strategy for the diagnostic evaluation of VTE will be reviewed.

Learning Objectives: 

• Review the measurement of D-dimer and sensitivity/specificity for the clinical evaluation of suspected venous thromboembolism.
• Describe the clinical utility of D-dimer in the diagnostic management of suspected upper extremity, lower extremity deep vein thrombosis, recurrent deep vein thrombosis and pulmonary embolism.
• Review the American Society of Hematology practice guidelines 2018 for the Diagnosis of Venous Thromboembolism.

Standardization and harmonization of coagulation testing methods have come a long way in the last 3 to 4 decades; however, standardization is imperfect.  Laboratory professionals need to recognize the limitations of some of our most commonly used coagulation tests.  The INR system has harmonized prothrombin time across methods and platforms for the purpose of monitoring warfarin, but the system does not harmonize very high INR values nor does it harmonize INR values in the setting of liver disease.  Many hospital-based laboratories perform a one stage factor VIII assay to support a wide range of clinical indications.  In the last decade, important biases have been demonstrated between one stage assays and chromogenic assays when diagnosing hemophilia A patients or monitoring new hemophilia therapies.  Finally, quantitative D-dimer assays have excellent negative predictive value to exclude venous thromboembolism.  Unfortunately, there is a lack of standardization, and even a lack of a standardized unit of measure.  Implementation of D-dimer requires careful attention to both the unit of magnitude and the unit type, especially when using different instrumentation across a laboratory system.

Learning Objectives:

• Recognize limitations of INR system
• Choose appropriate factor VIII and factor IX assays for various clinical indications
• Identify potential safety issues created by nonuniform D-dimer units and lack of standardization

LabRoots is approved as a provider of continuing education programs in the clinical laboratory sciences by the ASCLS P.A.C.E. ® Program. By attending this webinar, you can earn 1 Continuing Education credit once you have viewed the webinar in its entirety.

The compendium of newly emerging and currently available hemophilia and anticoagulant treatments, while offering new choices for improved patient care, can create significant levels of interference with routine and specialized laboratory coagulation assays. Our new educational session will examine the interference in coagulation tests from presence of the direct oral anticoagulants (DOACs) and the extended half-life (EHL) and non-factor products. It is important for laboratories to be aware of how both classes of these products, when present, can impact downstream results and clinical decision making.  

Upon completion of this session, participants will be able to:
1. Identify how to detect DOAC’s with routine coagulation tests and how they impact results.
2. Understand how the new EHL products for hemophilia A and B perform in relation to the laboratory’s coagulation reagents.
3. Increase awareness of the impact of these issues on coagulation testing.

This talk will cover different approaches to emergency hemostasis testing for patients that are actively bleeding due to trauma, surgery, obstetrical emergencies and other causes. The talk includes a discussion of rapid testing in the clinical laboratory, satellite laboratories and point of care testing using standard coagulation assays (prothrombin time, fibrinogen, platelet count and hematocrit) versus viscoelastic methodology. Critical aspects of emergency versus routine testing are reviewed and platelet function assays useful in rapid assessment of bleeding patients are discussed.

Learning Objectives

1. Describe the different types of coagulation assays used for emergency testing
2. Understand critical differences between routine and emergency testing
3. Understand role of platelet function testing

The International Council for Standardization in Haematology (ICSH) is a nonprofit organization dedicated to providing open-access guidance documents to enhance the quality of laboratory testing and practice.  A recently published ICSH initiative centered on providing laboratory guidance to 1) identify all coagulation tests with potential patient risk based on test methodology, test result, and patient presentations, 2) recommend critical result thresholds; 3) provide acceptable reporting and documenting mechanisms, and 4) delineate the required elements for  laboratory policies.  Theis presentation will describe the rationale for critical values/tests recommendations by renowned opinion leaders in the field of laboratory coagulation.

At the conclusion of this webinar attendees will be able to:
1) understand and define the difference between a critical value and a critical test,
2) describe the recommended coagulation tests with associated with critical values,
3) identify the recommended elements for reporting and documenting critical values, and
4) apply the recommended requirements for a critical value/test laboratory policy