Quality indicators for critical international normalized ratio measurements in a hemostatic laboratory.

OBJECTIVE: This study aimed at reviewing the quality indicators for reporting critical international normalized ratio (INR) in a coagulation laboratory. DESIGN AND METHODS: This is a retrospective study conducted at Aga Khan University Hospital, hemostatic laboratory from February 2010 till January 2011. Critical INR was defined as ≥5.0. All critical INRs were rechecked and results were communicated to the doctor or patient. Two quality indicators monitored were % of results communicated to the patient/doctor and % of results that remained critical after re-testing. RESULTS: During the study period, a total of 59,980 INRs were reported. Of these 376 or 0.6% were critical. Successful communication of critical results to the doctor or patient was achieved in 275/376 (73.1%). Overall 353 or 94% (343 initial and 10 re-draw) samples had critical INR on repetition. Twenty five patients of the 240 warfarinized patients with critical INR had mild bleeding. No life threatening bleeding was observed in any patient. CONCLUSION: We observed poor communication for notifying critical INR results during the study period. Routine repeat analysis of critical INR did not alter results in majority of samples. The study assisted in improving communication in subsequent years. Further work is needed to establish evidence based upper and lower cutoff of critical INR. Effect of replicate analysis on turnaround time and accuracy of results needs evaluation.

Deficiency of ADAMTS-13 in pediatric patients with severe sepsis and impact on in-hospital mortality.

BACKGROUND: The enzyme involved in regulating the size of vWF (von Willebrand factor) in plasma is ADAMTS-13 (A disintegrin and metalloprotease with thrombospondin type-1 motives). Deficient proteolysis of ULvWF (ultra large von Willebrand factor) due to reduced ADAMTS-13 activity results in disseminated platelet-rich thrombi in the microcirculation characteristic of thrombotic thrombocytopenic purpura. Reduced ADAMTS-13 has also been observed in severe sepsis and is associated with poor survival. We conducted this study to detect ADAMTS-13 deficiency and its impact on in-hospital mortality in pediatric patients with severe sepsis. METHODS: Pediatric patients diagnosed with severe sepsis were recruited for the study. Baseline clinical characteristics were noted. ADAMTS-13 antigen levels were assayed by ELISA. According to ADAMTS-13 levels, patients were grouped as deficient and non-deficient. Comparison was done with regard to some clinical and biological characteristics and in-hospital mortality between the two groups. RESULTS: A total of 80 patients were enrolled in the study. The median age of the patients was 3.1 years (Range: 0.1-15 years). ADAMTS-13 deficiency with levels less than 350 ng/dl was found in 65% patients. In patients with ADAMTS-13 deficiency, 75.6% had low platelets of less than 150 × 109/L. In-hospital mortality was 42.3% and 35.7% in ADAMTS-13 deficient and non-deficient group, respectively. CONCLUSION: Majority of the pediatric patients admitted to hospital with severe sepsis exhibit ADAMTS-13 deficiency. ADAMTS-13 deficiency might play a role in sepsis-induced thrombocytopenia. More studies are needed to evaluate the role of ADAMTS-13 deficiency on in-hospital mortality.