Determine the plasma level of unfractionated heparin (UFH) or low molecular weight heparin (LMWH)
UFH and LMWH are anticoagulants commonly used to decrease the risk of venous or arterial thrombosis.6-9 Overdosing with these medications can increase the risk of hemorrhage and inadequate dosing decreases the efficacy of anticoagulation. These drugs work as anticoagulants by enhancing the ability of plasma antithrombin to bind and inactivate the serine proteases XIIa, XIa, IXa, Xa, and thrombin. Therapeutic monitoring is commonly performed because of the wide interindividual variation in response to this therapy.
Historically, many laboratories have monitored heparin levels using the activated partial thromboplastin time (aPTT) test. A large number of conditions can complicate the use of the aPTT in monitoring UFH therapy.6 The College of American Pathologists (CAP) divided these factors into three groups.6 The first group of complicating factors encompasses those that affect the bioavailability of heparin. Aging, obesity, changes in heparin binding proteins, hepatic disease, renal disease, and heparin resistance fall under this heading. The second group of complicating factors includes those that alter the aPTT dose response to heparin. Increased factor VIII or fibrinogen levels, decreased antithrombin levels, or a mild reduction in multiple factors (as might be seen in the early stages of a consumptive coagulopathy or in oral anticoagulant therapy) are examples of this type of complicating factor. Lastly, those factors that tend to cause a prolonged aPTT in the absence of heparin therapy should be considered. Lupus anticoagulants or deficiency in contact factors can produce an extended baseline aPTT. In all of these cases, the heparin anti-Xa assay may be more appropriate for monitoring heparin therapy.
The aPTT should not be used for therapeutic monitoring of low molecular weight heparin because this drug typically does not affect the aPTT significantly.
Blue-top (sodium citrate) tube
Blood should be collected in a blue-top tube containing 3.2% buffered sodium citrate.1 Evacuated collection tubes must be filled to completion to ensure a proper blood to anticoagulant ratio.2,3 The sample should be mixed immediately by gentle inversion at least six times to ensure adequate mixing of the anticoagulant with the blood. A discard tube is not required prior to collection of coagulation samples, except when using a winged blood collection device (ie, “butterfly”), in which case a discard tube should be used.4,5 When noncitrate tubes are collected for other tests, collect sterile and nonadditive (red-top) tubes prior to citrate (blue-top) tubes. Any tube containing an alternate anticoagulant should be collected after the blue-top tube. Gel-barrier tubes and serum tubes with clot initiators should also be collected after the citrate tubes. Centrifuge and carefully remove the plasma using a plastic transfer pipette, being careful not to disturb the cells. Transfer the plasma into a PP transpak frozen purple tube with screw cap. Freeze immediately and maintain frozen until tested. To avoid delays in turnaround time when requesting multiple tests on frozen samples, please submit separate frozen specimens for each test requested.
Gross hemolysis; clotted specimen; frozen specimen thawed in transit; improper labeling