Method of monitoring treatment of indirect anticoagulants

 

The invention relates to medicine, in particular to the treatment with anticoagulants of indirect action. The method can improve the accuracy of monitoring treatment of indirect anticoagulants. Spend their introduction to the patient under the control of prothrombin time in capillary blood, while the prothrombin time is determined using standardized by the international sensitivity index of the thromboplastin and the molar ratio of the final concentration of anhydrous calcium chloride to a final concentration of anhydrous sodium citrate average of from 1.5 to 2.0, expect international normalized ratio (MPE) according to the formula INR=(PTpatientPW control)MICHIGANwhere ROpatient- prothrombin time in the capillary blood of the patient, ROcontrol- prothrombin time in capillary blood of a healthy person, ISI is the international sensitivity index of the thromboplastin, and under the control of MPE make the selection and dose adjustment of drugs, where MPE should be in the range from 2.0 to 4.0. table 2.

The invention relates to medicine, in particular to the study of blood, and can be used to identify the prevention of thrombosis and thromboembolism.

In 1983 the who [WHO 1211 Geneva 27 Switzerland. /Recommended methodology for using WHO International Reference Preparation for Thrombo-plastin], together with the Committee on thrombosis and hemostasis, it is recommended for monitoring the application of indirect anticoagulants (ON) the results of determination of prothrombin time platelet-poor plasma (BTP) to Express the exponent of the international normalized ratio (MPE or in English transcription INR - international normalized ratio). However, there is an urgent need to establish not only MPE in BTP, but in the capillary blood, especially in emergencies in paediatric practice and the selection of the dose.

There is a method of monitoring treatment of indirect anticoagulants by determining the prothrombin time in BTP, consisting in the determination of clotting time BTP when it is mixed with the thromboplastin - calcium mixture (Quick A. J. The prothrombin time in hemophilia and in obstructive jaundice. // J. Biol. Chem. - 1935. - Vol. 109. - P. 73-74). However, the method does not allow for the study of capillary blood for the investigated BTP there is an additional step, namely centrifugation stabilized by citrate venous blood.

Closest to the claimed solution achieved positive results assetmanage time in capillary blood (guidelines on the application of standardized clinical laboratory studies, approved by Order of the Minister of health of the USSR 960 dated October 15, 1974, edited by C. C. Menshikov, M., 1977, c. 27-29).

The prototype method is as follows.

Reagents for performing the method of the prototype: 1. a 3.8% solution of sodium citrate; 2. a 0.5% solution of calcium chloride; 3. 1% solution of thromboplastin.

The equipment for performing the method of the prototype 1. Water bath at +37oC.

2. Stopwatches.

3. The scarifiers.

4. Micropipette with a displacement measurement to 0.1 ml.

Study of the method of the prototype: capillary stabilized with citrate, blood.

Move the definition of the prototype method. In micropipette gain of 0.02 ml of a solution of sodium citrate. The pulp of the finger of a healthy person is wiped with alcohol, and after drying it make a puncture with a sterile scarificator. Trying to enter in the same micropipette 0,08 ml free serving of blood, immediately blow away the contents in the test tube and mix the blood with the anticoagulant. Just trying citrate blood in two test tubes. Each tube set sequentially in a water bath at a temperature of +37oFrom and after 1 min add 0.1 ml of a solution of calcium chloride and 0.1 ml of thromboplastin. At the time of adding what about the results in three test tubes compute the average.

Similarly spend getting stabilized by citrate capillary blood and the determination of the prothrombin time in the patient.

Evaluation of results by the method of the prototype. Prothrombin activity in the blood was determined by the formula: PAK(%)=(a/b)X100, where PAK is an indicator of prothrombin activity of the blood; And - prothrombin time in capillary blood of a healthy person; the prothrombin time in the capillary blood of the patient.

The normal rate of prothrombin activity of the blood is 93-107%. In the treatment of indirect anticoagulants, this figure should be in the range of 45-65%.

The disadvantages of the prototype method are the following.

1. A non-standard way of expressing the results of the study do not take into account the sensitivity of the used device to the deficit-To-vitaminsvitamin factors of the prothrombin complex (factors VII, X, II).

2. The disparity between the results by the method of the prototype with the results of the method for determining prothrombin clotting time in BTP in patients receiving. This is due to the mismatch used in final concentrations of sodium citrate and calcium chloride in the method prototype in comparison with those of Conn of these shortcomings: when evaluating the results of prothrombin test in patients receiving, account for the sensitivity of the thromboplastin to deficiency of factors of the prothrombin complex; the results of the method expressed in the standard (recommended by who) indicator MPE, the results of determination by the claimed method in patients receiving TO coincide with the results of the method was performed in the same patients at BTP.

The authors propose a method that allows high accuracy to determine the prothrombin time in capillary blood, as it is proposed to use a standardized according to the international index of thromboplastin in the study of capillary blood. In addition, in the present method is used, the optimum ratio of sodium citrate and calcium chloride, which is completely possible to reproduce the results obtained in the study BTP patients. Thus, the inventive method has all the advantages of the method definition for BTP (analog), but does not require the additional step of centrifugation, which significantly improves its accessibility (to increase the number of medical institutions where it is possible to perform this test, namely, district hospitals, health posts, health centres and other small medical institutions), as in the study of the surveys. In addition, in the study by the claimed method prothrombin time in newborns (all newborns reduced the level of factors of the prothrombin complex, particularly important in this study with neonatal jaundice) eliminates the need for puncturing the surface of the frontal vein to obtain 3 ml of venous blood, and is an accurate study of prothrombin time in capillary blood (for research only enough to 0.20 ml of blood), with overdose and during the selection of the dose of indirect anticoagulants, as there is a risk of life-threatening bleeding, the recommended daily definition of MPE, this indicator, as it is known, to determine the way the prototype is not possible, using a method similar additionally required venipuncture for collection of 9 ml of venous blood and the necessary additional step of centrifugation of blood.

The positive results of the proposed method are improving the accuracy of control.

A positive result is achieved due to the fact that use standardized by the international sensitivity index of the thromboplastin, and the molar ratio of the final concentration of anhydrous calcium chloride to a final concentration of anhydrous tie 1. a 3.8% solution of sodium citrate. Receive by dissolving 3.8 g translesanas sodium citrate (5,5 water) in 100 ml of distilled water.

2. Lyophilized thromboplastin reagent "Techplast" production company "Technology Standard", Barnaul, Russia (standardized by the international sensitivity index - ISI). Before using the reagent is diluted by adding 5.0 ml of a solution of calcium chloride at a concentration taken in the range from 0,0325 M to 0,0400 M, incubated in a water bath at a temperature of +37oWith not less than 15 minutes

3. Coagulometer, type Thrombostat-2 (firm Behnk Elektronik").

4. The scarifiers.

5. Capillary Panchenkov.

6. Micropipette with a capacity of 0.1 ml 5,0 ml

7. Tubes of glass.

8. Alcohol 70o.

9. Sterile cotton balls.

Obtaining capillary blood
1. Capillary Panchenkov wash of 3.8% solution of sodium citrate;
2. After treatment with alcohol and puncture the flesh of the finger scarificator the first drop of blood to be removed with a cotton swab.

3. In the capillary gain of 3.8% solution of sodium citrate to divide "80".

4. Move citrate into a clean tube.

5. In the same capillary tube to collect the blood to fission "0".

6. The received blood to move into a clean tube.

7. In toeradicate their pipetting. This gets the blood stabilized by 3.8% solution of sodium citrate in the ratio of 9:1. Prior to the study (period of time not more than 60 min) blood samples stored at room temperature (+18...+25o(C) in a tightly closed to prevent drying.

The process of determining
The analyzed sample of capillary blood of the patient, in a volume of 0.1 ml, incubated for 1 min in a ditch of coagulometer at +37oC. Then make a 0.1 ml heated to a temperature of +37oWith the thromboplastin-calcium reagent include a timer (stopwatch) and determine the clotting time.

This study of the capillary blood of the patient is performed twice. Of the two definitions compute the average result of prothrombin clotting time (in second).

Similarly investigate capillary blood stabilized with citrate, taken from a healthy person.

An assessment of the results
The results are judged by the international normalized ratio (MPE), calculated by the formula:
INR=(PTpatientPWcontrol)Michigan,
where MPE - international normalized ratio;
ROpatient- prothrombin time in the capillary blood of the patient;
ROcontrol- Pro is omoplata.

According to a survey of 45 healthy individuals revealed that the average rate of MPE in capillary blood (Xm) is equal to 1,0100,003 (= 0,02). The survey capillary blood 128 patients with various disorders that require the use of indirect anticoagulants, it was found that the rate of MPE in the range from 2.0 to 4.0 effectively prevents thrombotic disorders and does not cause any bleeding.

Testing of the proposed method
Tested the proposed method of diagnosis conducted on 128 patients receiving anticoagulants of indirect action. A comparison of prothrombin time obtained by different methods, was conducted on 10 patients who were installed artificial heart valves. Comparison of indicators are presented in table.1. It shows that using the proposed method, the effect of the application TO evaluate the exponent of the MPE and these results coincide with the MPE values determined in citrate platelet-poor plasma (the correlation coefficient was +is 0.998, p<0,001). The table shows that the performance of the proposed method is not affected by the use of different the different thromboplastins).

The reproducibility of the method
To assess the reproducibility of the method used, the coefficient of variation CV(%). The coefficient of variation of the proposed method in the study on different days does not exceed 5%.

Optimization results the final concentration of sodium citrate and calcium chloride
To obtain a high comparability of the research results of the proposed method with the results of the method using BTP, we have estimated the molar ratio of the final concentration in the test mixture of calcium chloride and sodium citrate.

For this purpose, we used the formula:

where MS is the molar ratio;
S1- the final concentration of calcium chloride (calculated on anhydrous) in the tested mixtures;
S2- the final concentration of sodium citrate (calculated on anhydrous) in the test mixture.

Using this formula it is established that the molar ratio of the final concentration of anhydrous calcium chloride to a final concentration of anhydrous sodium citrate in the method prototype is 2.12.

To clarify the optimal range of the molar ratio of the final concentration in the test mixture of sodium citrate and calcium chloride of predstavleny in table. 2. The table shows that the optimal range of the molar ratio of the final concentration of anhydrous calcium chloride to a final concentration of anhydrous sodium citrate is in the range from 1.5 to 2.0.

Clinical examples
1. Patient M. S., 43 years old, was admitted to the Department of heart diseases Altai regional cardiologic dispensary 19.01.99 with a diagnosis of Rheumatic fever, inactive phase; Status post mitral valve replacement (1989); Permanent form of atrial fibrillation, NC-II and; the consequences of violations of cerebral circulation in the basin of the middle cerebral artery with right-sided hemiparesis and events dysarthria. Purpose of admission - selection and dose adjustment of indirect anticoagulants. From the anamnesis it is established that in the last 5 days, the patient has faced long-term (over 40 minutes) nosebleeds. In the study of prothrombin time 19.01.99, the patient revealed a pronounced hypocoagulation on a background of application of 0.2 mg plantana. Figure MPE in capillary blood, the claimed method, amounted to 7.8, indicating a significant overdose of this drug and is at high risk of developing life-threatening bleeding. In St. the detected decrease in MPE to 1.9 only 21.01.99. With 22.01.99 plantan newly appointed in the half dose of 0.1 mg Nasal bleeding or other symptoms bleeding during correction of the dose was not observed. The daily study of the prothrombin time by the claimed method, to 25.01.99 indicator MPE reached 3.5, i.e., is recommended for these patients range.

2. Patient T. C., 36 years old, was admitted to the cardiac surgery Department of the Altai regional cardiologic dispensary 20.10.98 with a diagnosis of Chronic bacterial endocarditis with lesions of the mitral valve. Mitral valve insufficiency, HK-II B. the Patient 02.12.98 made surgery mitral valve replacement in conditions of artificial blood circulation. Has a prosthetic mitral valve LIX-36. With 08.12.98 the patient is assigned an indirect anticoagulant - phenylin at a dose of 30 mg/day. In the study of hemostasis 11.12.98 (on the fourth day of admission indirect anticoagulants) MPE in capillary blood was 1.6, which was seen as insufficient dose of indirect anticoagulants and the dose was increased to 15 mg/day (30 to 45 mg per day). The daily study only to 16.12.98 on the background of both dose revealed an increase in MPE to 3.4. In financial p is/day, and the MPE in the next 12 months were maintained in the recommended for these patients range.

3. Patient K. M., 33, filed in the Altai Hematology center 12.03.99 with complaints uterine bleeding (b=77 g/l) and the presence of subjective symptoms sideropenic syndrome. From the anamnesis it is established that the patient within 5 months applies indirect anticoagulants (Venelin at a dose of 60 mg), selection and control doses were held on indicator PAK in capillary blood (the method prototype) at the hospital of the city of Biysk. From the patient card is installed, this indicator over the last 4 months was in the range of 55-65% (i.e., selection and dose adjustment fenilina were carried out without taking into account the sensitivity index of the thromboplastin). In the study of capillary blood by the claimed method indicator MPE was 5.7, which indicates a significant overdose of this drug and is at high risk of developing life-threatening bleeding. Was reduced dose up to 45 mg and conducted daily monitoring of the prothrombin time in capillary blood, the claimed method. Figure MPE reached the recommended level of 2.6 to 21.03.99. Any bleeding or other symptoms krovotochivost endovenosa who) indicator MPE in capillary blood. Full comparability of results of determination by the claimed method with parameters obtained at BTP, unlike the prototype method, because there is an optimization of the final concentrations of sodium citrate and calcium chloride. Reducing the time of the study, in comparison with the method of the similar because there is no additional step is the preparation of platelet-poor plasma, namely centrifugation. In addition, to run the test there is no need for additional equipment for carrying out centrifugation (centrifuge, centrifuge the cell), and for performing the method-analogue of this equipment.


Claims

Method of monitoring treatment of indirect anticoagulants by the patient under the control of prothrombin time in capillary blood, characterized in that the prothrombin time is determined using standardized by the international sensitivity index of the thromboplastin and the molar ratio of the final concentration of anhydrous calcium chloride to a final concentration of anhydrous sodium citrate average of from 1.5 to 2.0, expect international normalized ratio (MPE) according to the formula

INR=(PTcontrol- prothrombin time in capillary blood of a healthy person;

ISI is the international sensitivity index of the thromboplastin,

and under the control of MPE make the selection and dose adjustment of drugs, where MPE should be in the range from 2.0 to 4.0.

 

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FIELD: medicine, laboratory diagnostics.

SUBSTANCE: the suggested studying should be carried out on the glass simultaneously with several inductors by applying minimal inter-taking antilogarithms concentrations of aggregation inductors which correspond at double combination of inductors: ADP 5.0 x 10-8 M, adrenaline 3.0 x 10-9, collagen - dissolving the main suspension 1:8, thrombin 0.075 U/ml; at triple combination of inductors: ADP 10-9 M, adrenaline 10-9, collagen - dissolving the main suspension 1:9, thrombin 0.060 U/ml. The development of aggregation means thrombocytic activation in patients with arterial hypertension at metabolic syndrome. The method enables to evaluate the changes of thrombocytic functional state with combination of inductors more probably present in area of vascular lesion by applying minimal necessary concentrations that develops real conditions at hemostatic initiation in human vessels.

EFFECT: higher efficiency of studying.

3 dwg, 3 ex, 2 tbl

FIELD: medicine.

SUBSTANCE: method involves checking consciousness, blood coagulation state, peripheral blood leukocytes number, K+ ions, bilirubin, fibrinogen, hemolysis and hemoglobinuria availability, prothrombin index and exotoxic shock development. Each value is calculated in points as follows. Lucidity is evaluated as -2 points; depression - +3 points; coma - +6 points; lack of changes in blood coagulation system - -2 points; coagulation availability without clinical injuries - +2 points; coagulopathy with clinical manifestation signs - +19 points; K+ ions concentration being less than 3.0 mmole/l - +3 points, from 3.1 to 3.5 mmole/l - -5 points, from 3.6 to 5.0 mmole/l - 0 points, greater than 5.0 points - +7 points, failure in determining K+ ions concentration - 0 points; hemolysis availability - +6 points, its lack - -3 points; hemoglobinuria availability - +8 points, its lack - -1 points; leukocytes number being less than 12.0x109/l - -2 points, from 12,1 to 18.0x109/l - 0 points, higher than 18.0x109/l - +8 points; hourly urine output being less than 30 ml/h - +6 points, greater than 30 ml/h - -2 points; bilirubin content being less than 31 mcmole/l - -2 points, from 30.1 to 50.0 mcmole/l - 0 points, greater than 50.0 mcmole/l - +2 points, failure in determining bilirubin content due to hemolysis being available -+6 points; prothrombin index being equal to or less than 60% - +3 points, greater than 60% - 0 points, failure in determining prothrombin index due to hemolysis being available - +12 points; fibrinogen concentration in blood plasma being less than 2.1 g/l - +4 points, from 2.1 to 4.0 g/l - -1 point, from 4.1 to 6.0 g/l - +1 point, failure in determining fibrinogen concentration due to erythrocyte hemolysis being available - +13 points; exotoxic shock development - +9 points, its lack - -1 point. The points are summed up. The value being greater than +13, admission for treatment in resuscitation department is indicated. The value being less than -13, admission for treatment in therapeutics department is indicated. The value being from -13 to +13, resuscitation expert consultation is advised.

EFFECT: high evaluation accuracy.

3 tbl

FIELD: medicine, laboratory diagnostics.

SUBSTANCE: one should evaluate the time for clotting of plasma under testing in phospholipid-dependent test, moreover, one should apply high- and low-sensitive thromboplastin reagents to lupus anticoagulant to calculate the ratio of indices of prothrombin time prolongation and at its value being either equal to or above 1.1 one should diagnose APS.

EFFECT: shortened terms of research.

1 ex, 4 tbl

FIELD: medicine.

SUBSTANCE: method involves analyzing symptoms manifesting initial disseminated intravascular blood coagulation syndrome danger like burn area, availability of upper air passages burn, shock with its severity degree taken into consideration, sepsis development; clinical manifestations of disseminated intravascular blood coagulation syndrome like lung, kidney, liver function insufficiency, cerebral dysfunction, local and multiple hemorrhages, thrombosis, infarction; homeostasis system laboratory analysis data, hyper- and hypocoagulation based on chronometry test data, number of blood platelets, fibrin-monomer complexes, D-dimers, activity of antithrombin III, C and S proteins, XIIa-dependent fibrinolysis plasminogen content, availability of injured erythrocytes, combinations of laboratory tests for recognizing disseminated intravascular blood coagulation syndrome. Each sign under consideration receives a number of points corresponding to its diagnostic significance and integral value is calculated DIBCSIV=(X1+X2+…+Xn)/n, where n is the number of signs taken into consideration. DIBCSIV value equal to 1.0-1.5 units shows physiological norm. The value being between 1.6 and 2.5 units, light disseminated intravascular blood coagulation syndrome is diagnosed. The value being between 2.6 and 3.5 units, disseminated intravascular blood coagulation syndrome of medium severity is diagnosed; 3.6-4.5 points to one heavy severity degree; 4.6 and greater indicates highly severe case of disseminated intravascular blood coagulation syndrome.

EFFECT: high accuracy and objectiveness in differentiating syndrome severity degrees.

1 tbl

FIELD: medicine, diagnostics.

SUBSTANCE: one should study blood components to detect anticoagulant-fibrinolytic activity. Moreover, patient's blood should be sampled: in whole blood one should detect the presence of affected erythrocytes and evaluate the quantity of thrombocytes, in plasma it is necessary to study the activity of antithrombin III, XIIa-dependent fibrinolysis, the content of soluble fibrin-monomeric complexes, in blood serum of the sample taken one should detect the concentration of urea, creatinine, sodium, albumin, total cholesterol and the activity of aspartate aminotransferase, moreover, one should calculate integral value of renal-hepatic deficiency, to put corresponding point for the degree of parameters under testing, then one should calculate integral value of disseminated intravascular clotting (IVDIC) and at its value being 6.3 U and more DIC-syndrome should be diagnosed, moreover, at IVDIC value ranged 6.3-10.1 U it is possible to diagnose latent DIC-syndrome, at 10.2-14.6 - subacute DIC-syndrome and at 14.7 and higher - acute DIC-syndrome should be concluded.

EFFECT: higher accuracy and efficiency of diagnostics.

4 ex, 2 tbl

FIELD: medicine, obstetrics.

SUBSTANCE: the present innovation deals with predicting disadaptive processes in women in dynamics of menstrual cycle. During menstrual cycle beginning since the 1st d to the 21st d one should detect the dynamics for alteration in coefficient of activity of syntoxic adaptation programs (CASAP), calculated by the following formula:

where CST - concentration of blood serotonin, AAT-III - activity of antithrombin III, Aaoa - total antioxidizing activity of plasma, CCD8+ - concentration of T-suppressors, Cad - concentration of blood adrenalin, Cα2MG - concentration of α2-macroglobulin, CMDA - concentration of malonic dialdehyde, CCD4+ - concentration of T-helpers. Moreover, normally CASAP value alters two-fold against the first day of the cycle - since 0.70 up to 1.40 on the 21st d of the cycle, at no alterations in CASAP value one should diagnose female disadaptive alterations leading to failed pregnancy. The innovation enables to perform diagnostics of disadaptive processes in women in dynamics of menstrual cycle followed by prognostic conclusion upon future pregnancy.

EFFECT: higher accuracy of diagnostics.

2 ex

FIELD: medicine.

SUBSTANCE: method involves determining spontaneous blood platelets aggregation and one induced by adrenalin and collagen, thrombocytospecific peptides activity of β-thromboglobulin and thrombocytic factor 4 in blood plasma.

EFFECT: high accuracy of diagnosis.

2 tbl

FIELD: medicine.

SUBSTANCE: method involves determining coagulating blood viscosity values like reaction period r, thrombin constant K, maximum amplitude MA, time T for forming fibrin-thrombocytic blood clot, spontaneous blood platelets aggregation intensity Ar, retraction and spontaneous clot lysis total FA. The r being within 5-7 min, Ar from -2 to -6 relative units, K being within 4-6 min, MA within 500-700 relative units, T within 40-60 min and FA equal to 10-20%, low inflammatory process activity is considered to be the case. The r being less than 5 min, Ar equal to -8 to -12 relative units, T less than 40 min and FA less than 10% with no changes in K and MA being observed, inflammatory process activity in chronic glomerulonephritis case is considered to be of high severity degree.

EFFECT: high accuracy of diagnosis; enhanced effectiveness of treatment method selection.

1 dwg

FIELD: medicine, clinical neurology, neurosurgery.

SUBSTANCE: one should study both activation and aggregation of thrombocytes in blood of carotid artery, at the quantity of thrombocytic active forms being above 70% and the number of aggregated thrombocytes being above 9.0% one should predict the development of cerebral ischemic lesion along with stable focal neurological symptomatology, and at the quantity of thrombocytic active forms being below 30% and the number of aggregated thrombocytes being below 8.0% it is possible to predict positive dynamics in the course of the disease mentioned without developing cerebral ischemic lesion.

EFFECT: higher accuracy of prediction.

2 ex

FIELD: medicine, clinical neurology, neurosurgery.

SUBSTANCE: one should study the level of von Willebrand's factor in patient's carotid artery blood. At its content being below 105% one should predict the development of repeated AICH. The innovation improved information value of testing due to possibility to obtain reliable prediction in latent period, as well.

EFFECT: higher accuracy of prediction.

2 ex, 1 tbl

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