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  In this article
Abstract
Introduction
Case Report
Discussion
Conclusion
References
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  Table of Contents 
CASE REPORT
Year : 2017  |  Volume : 18  |  Issue : 1  |  Page : 23-26
 

Unbelievable but true: Partial thromboplastin time, kaolin 120 s and yet no surgical bleed!


Department of Anaesthesia, Rajiv Gandhi Cancer Institute and Research Centre, New Delhi, India

Date of Web Publication27-Jun-2017

Correspondence Address:
Shagun Bhatia Shah
H. No: 174 – 175, Ground Floor, Pocket - 17, Sector-24, Rohini, New Delhi - 110 085
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/TheIAForum.TheIAForum_8_17

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  Abstract 


Partial thromboplastin time, kaolin (PTTK) is a global test sensitive to low levels of all the coagulation factors, except Factor VII and Factor XIII. Patients with extensive cancer have a propensity to develop a shortened PTTK. Our breast cancer patient had a prolonged PTTK result roughly 4 times the normal values. A detailed description of the preoperative workup including the special investigations is required to ascertain the cause of the prolongation and precautions taken, leading to successful breast cancer surgery and postoperative period in this patient follows. Allowing the surgeon to operate a patient with a PTTK >120 s and simultaneously at risk of thrombosis due to lupus anticoagulant is possible with a calculated risk and thorough preoperative evaluation. Prophylactic fresh frozen plasma and deep venous thrombosis prophylaxis have an important role.


Keywords: Breast cancer surgery, decreased Factor XI, lupus anticoagulant, raised partial thromboplastin time kaolin, thromboelastography


How to cite this article:
Shah SB, Bhageria V, Naithani BK, Bhargava AK. Unbelievable but true: Partial thromboplastin time, kaolin 120 s and yet no surgical bleed!. Indian Anaesth Forum 2017;18:23-6

How to cite this URL:
Shah SB, Bhageria V, Naithani BK, Bhargava AK. Unbelievable but true: Partial thromboplastin time, kaolin 120 s and yet no surgical bleed!. Indian Anaesth Forum [serial online] 2017 [cited 2019 Sep 19];18:23-6. Available from: http://www.theiaforum.org/text.asp?2017/18/1/23/208970



  Introduction Top


An activator for speeding up the clotting time results in a narrower reference range making activated partial thromboplastin time (aPTT) a more sensitive version of partial thromboplastin time (PTT). The reference range of the aPTT is 30–40 s whereas that of PTT is 60–70 s.[1],[2] Spontaneous bleeding is signified by aPTT >70 s or PTT >100 s.[1],[3],[4] PTT, kaolin (PTTK) stands for aPTT where the activator is kaolin. Successive PTTK values grossly exceeding these critical values prompted a clinical red alert in our patient posted for semi urgent breast cancer surgery. A gripping account of how we weighed the pros and cons and proceeded for surgery with a calculated risk is described below.


  Case Report Top


Our patient was a 36-year-old female weighing 68 kg diagnosed with carcinoma right breast and posted for modified radical mastectomy. She gave a negative history of menorrhagia, spontaneous bleeds, epistaxis, or prolonged bleeding from cuts. She had been diagnosed with hypothyroidism 3 years back but was currently euthyroid (T3-5.82; T4-19.5; and TSH - 2.44) on oral thyroxine 75 μg once daily. Her hemoglobin (9.9 g%), packed cell volume (35.5), mean corpuscular volume (69.4), mean corpuscular hemoglobin (19.2), and mean corpuscular hemoglobin concentration (29.9) were marginally low. Her red cell distribution width coefficient of variation [5] (RDW CV) was 20.4 (normal range being 11.6–14.6), indicating anisocytosis. The platelet count (616,600/mm 3) was high (reconfirmed by performing manual platelet count). Prothrombin time was 13.3 and international normalized ratio was 0.94.

Her PTTK was 120 s on presentation, and on this basis, she was declared unfit for surgery. PTTK refused to come down despite intravenous (IV) infusion of four units of fresh frozen plasma (FFP). Mixing studies were unable to correct the PTTK results. Factors VIII (105.9%), IX (90.7%), and XII (109.8%) levels were within normal limits. On estimation of Factor XI functional levels by the photo-optical clot detection method, a mild deficiency (60.3%) was detected (normal range being 70%–120%). Results were clinically correlated and the test conducted on citrated plasma. Dilute Russell's viper venom test (DRVVT) screen ratio was 1.4, DRVVT mix ratio was 1.2, and DRVVT confirm ratio was1.4 (data consistent with the presence of lupus anticoagulant [LA] found in systemic lupus erythematosus patients). The patient was screened for heparin and coumarin therapy. Her blood glucose, kidney function tests, serum electrolytes, liver function tests and other biochemical tests, ECG, and chest X-ray were within normal limits. Keeping another four units of FFP arranged in case of major intraoperative bleeding, she was given clearance for surgery after 10 days of investigations and unsuccessful attempts at optimization of PTTK by an hemato-oncologist. Preoperative evaluation for isolated prolonged PTTK is summarized in [Figure 1].
Figure 1: Preoperative evaluation for isolated prolonged partial thromboplastin time, kaolin

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A 20-gauge IV line was secured in the operation theater. The patient was premedicated with 1 mg midazolam and anesthesia induced with 70 mg propofol, 80 μgm fentanyl, and 40 mg atracurium. The trachea was atraumatically intubated with a cuffed polyvinylchloride orotracheal tube (7 mmID; Portex) followed by auscultatory and capnographic confirmation of endotracheal tube placement. Maintenance agents were oxygen, medical air, sevoflurane, atracurium boluses, and fentanyl 40 μgm. A thromboelastogram [6] blood sample was obtained before surgical incision. The total blood loss was 250 ml, and 1000 ml of physiological crystalloid (plasmalyte) and two units of FFP were infused intraoperatively. Mechanical deep vein thrombosis (DVT) prophylaxis was given using DVT calf pump. The patient was hemodynamically stable throughout surgery which lasted for 90 min and anesthesia reversed with neostigmine-glycopyrrolate combination. Morphine 4.5 mg IV 6 hourly was utilized for postoperative pain relief, and nonsteroidal anti-inflammatory drugs were avoided. Dexamethasone 8 mg and ondansetron 8 mg were injected for postoperative nausea-vomiting. DVT stockings were used and the patient was ambulated early.


  Discussion Top


The PTTK is used to evaluate all the clotting factors of the intrinsic and common pathways of the clotting cascade (Factors I [fibrinogen], II [prothrombin], V, VIII, IX, X, XI, and XII) by measuring the time taken for clot formation after adding calcium and phospholipid emulsion to a plasma sample.[4],[7] The result is always compared to a control sample of normal blood.
Figure 2: Standard kaolin thromboelastogram of the patient

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Indications and interpretation of PTTK are included in [Table 1]. A prolonged PTTK results from either clotting factor deficiency or anticoagulants [Table 2].[4],[7] Of these causes, mild Factor XI deficiency and elevated DRVVT ratios were discovered in our patient.
Table 1: Tabulation of relevant tests done and their significance in light of the present patient

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Table 2: Causes of prolonged partial thromboplastin time, kaolin

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Factor XI or plasma thromboplastin antecedent deficiency (hemophilia C) is common in Ashkenazi Jews [9],[10] (8% of heterozygotes). Being an autosomal inherited disorder, unlike hemophilia A and B (X-linked), it affects both genders equally. Women experience menorrhagia and postpartum hemorrhage. It is the second most common bleeding disorder affecting women after von Willebrand disease. The frequency of bleeding with hemophilia C is not determined by the patient's factor level or severity of the deficiency, bleeding may not occur even at 10% levels while massive bleeding may follow surgery in patients with 60% levels.[9],[10] Unpredictable and variable bleeding patterns observed in people with hemophilia C complicate management. Spontaneous bleeding is uncommon, but bleeding tends to occur after trauma or surgery. Unlike hemophilia A and B, bleeding into joints and muscles is not observed in hemophilia C and patients experience milder symptoms. They do not require treatment or prophylaxis for routine activities. Replacement therapy with FFP is essential prior to tooth extractions and surgery.

We took utmost care to avoid factors interfering with the PTTK test.[4],[7] Drugs known to prolong PTTK (antihistamines, ascorbic acid, chlorpromazine, heparin, and salicylates) were avoided. Correct blood-to-citrate ratio (9:1), not drawing blood samples from a heparinized catheter or after lipid meals were the other precautions taken. The whole blood sample containing blue top vacutainer was stored at 4°C and tested within 4 h of collection.


  Conclusion Top


A persistently and extremely elevated laboratory value of PTTK (120 s) may not have any clinical significance and may not be a contraindication for safe surgery. Clinical factors override the significance of abnormal laboratory tests. Despite the fact that extensive cancer is associated with a shortened PTTK, our patient demonstrated an extremely prolonged PTTK presumably due to low Factor XI levels (hemophilia C) and presence of LAs.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.

 
  References Top

1.
Tripodi A, Lippi G, Plebani M. How to report results of prothrombin and activated partial thromboplastin times. Clin Chem Lab Med 2016;54:215-22.  Back to cited text no. 1
[PUBMED]    
2.
Kitchen S, Jennings I, Woods TA, Preston FE. Wide variability in the sensitivity of APTT reagents for monitoring of heparin dosage. J Clin Pathol 1996;49:10-4.  Back to cited text no. 2
[PUBMED]    
3.
Lippi G, Favaloro EJ. Activated partial thromboplastin time: New tricks for an old dogma. Semin Thromb Hemost 2008;34:604-11.  Back to cited text no. 3
    
4.
Pagana KD, Pagana TJ, editors. Blood studies. Mosby's Manual of Diagnostic and Laboratory Tests. 4th ed., Ch. 2. St. Louis: Mosby Elsevier; 2010.  Back to cited text no. 4
    
5.
Sultana GS, Haque SA, Sultana T, Ahmed AN. Value of red cell distribution width (RDW) and RBC indices in the detection of iron deficiency anemia. Mymensingh Med J 2013;22:370-6.  Back to cited text no. 5
    
6.
Whitten CW, Greilich PE. Thromboelastography: Past, present, and future. Anesthesiology 2000;92:1223-5.  Back to cited text no. 6
    
7.
Fischbach FT, Dunning MB 3rd, editors. Overview of chemistry studies. Manual of Laboratory and Diagnostic Tests. 8th ed., Ch. 6. Philadelphia: Lippincott Williams & Wilkins; 2009.  Back to cited text no. 7
    
8.
O'connor CR, Reginato AJ, Ing JH, Keech JA. Prolonged activated partial thromboplastin time in systemic lupus erythematosus overlap syndrome: Fatal bleeding due to factor VIII inhibitor. J Clin Rheumatol 1995;1:57-9.  Back to cited text no. 8
    
9.
Gomez K, Bolton-Maggs P. Factor XI deficiency. Haemophilia 2008;14:1183-9.  Back to cited text no. 9
    
10.
Asakai R, Chung DW, Ratnoff OD, Davie EW. Factor XI (plasma thromboplastin antecedent) deficiency in Ashkenazi Jews is a bleeding disorder that can result from three types of point mutations. Proc Natl Acad Sci U S A 1989;86:7667-71.  Back to cited text no. 10
    


    Figures

  [Figure 1], [Figure 2]
 
 
    Tables

  [Table 1], [Table 2]



 

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