Help! Lab INR test rejected due to Hemolysis

Advertise with us
Shop deals on ebay
shop deals on amazon
Valve Replacement Forums

Help Support Valve Replacement Forums:

This site may earn a commission from merchant affiliate links, including eBay, Amazon, and others.
D

doyo

VR.org Supporter
Supporting Member
Joined
Aug 28, 2006
Messages
75
Location
Virginia
7 weeks post-op, my wife's INR is still unstable.
We have been doing the vein draw at the lab.
When outside the range, always below, never over the range which is bad.

Finally got her doctor to try to manage it high in the range after it got down to 1.6 last week.
The doctor ordered a large dose increase (much larger than I would've chosen, from 3.5 mg to 5 mg).
My wife's does have been ever increasing as she recovers more, so maybe he was right.
After 6 days of 5 mg, INR went up to 2.4 (he was right, even 5mg did not raise it as much as I expected)
At INR 2.4, the doctor said maybe it will go up or maybe it will go down from 2.4.
To be sure, continue on 5mg and test it in 2 days. Then he will make the dose adjustment.

2 days passed and today I took her to the lab.
Called the lab in the afternoon and found out that today's test was rejected due to Hemolysis!:eek:

My understanding of Hemolysis is breaking down of red blood cells, resulting in a low Hematocrit % (low red blood cell % in the blood).
I heard this is not uncommon with the mechanical valve that chopps up the red blood cell.
I heard even some tissue valve can cause this.

To make the long story short, we do not have her INR result at the critical time.
I plan to take her to the lab the first thing tomorrow morning.
The test rejection due to Hemolysis is just one time thing or will it happen again?
Can lab do something to adjust their machine or regeant to account for the hemolysis (low Hematocrit)?
I am using the term hemolysis and low hematocrit interchangeably in this context, correct me if I am wrong.

I am in the process of getting the home INR monitor but I think home INR monitor has narrower hematocrit range than the lab machine so it is a
concern for the long term. But we need to figure out this immediate problem first. I hope Al will visit the forum tonight..

Thanks,
EJ
 
EJ is she a hard stick or hard to find veins to draw from? The person taking the blood could be the cause of the hemolysis. If you've been able to test fine all this time and this is new, this is what I would suspect. At any rate, don't worry about the INR so much. She's nearly in range and as long as it's not above 5.0 when you get a valid test, there isn't anything to worry about. The average person requires 5mg per day to attain in range readings. Some much more, some much less.
 
Hemolysis can occur in the body or outside of the body. Hemolyized blood cells in the circulation are rapidly removed by the liver and spleen, often in one pass through. The hemoglobin released from these damaged cells circulates in the blood stream and will be excreted in the urine giving it a pink color. The free circulating hemoglobin is broken down in the liver. If the amount of hemoglobin exceeds the livers rate of conversion then jaundice will develop. Except under unusual circumstances, a heart valve will not cause enough hemolysis to give pink serum or pink urine.

THE MOST LIKELY cause of the hemolysis in the test tube is poor technique or handling of the specimen. I see little point in going into the many causes of this. Considering the fact that the change in INR lags a period of time after dose change, getting the test done tomorrow should be of little consequence.
 
Ross said:
EJ is she a hard stick or hard to find veins to draw from? The person taking the blood could be the cause of the hemolysis. If you've been able to test fine all this time and this is new, this is what I would suspect. At any rate, don't worry about the INR so much. She's nearly in range and as long as it's not above 5.0 when you get a valid test, there isn't anything to worry about. The average person requires 5mg per day to attain in range readings. Some much more, some much less.
Click to expand...


Ross as much as it scares me to say this, we think too much alike these days. i was going to suggest that the hemolisis could be from a bad blood draw, lyn
 
Thanks DrAllan, Lyn, and Ross (special thanks to Ross for help with the registration).

Yes, Ross. Her vein in the arms had been spent after 2 hospital stays.
The draw has been done by the same good/careful technician at this lab.
This technician has been drawing from left hand to give her arm veins a break.
Today, my wife was brave to try the left arm again, but nothing came out.
So the technician tried her left hand and the left hand said, no more (no blood there either).
So the technician drew from the right hand. It flowed out well in the first try. I was eyeing her ankle as this was being done...:( Luckily she did not notice this :D

Right arm has been off limit due to the right subclavian bypass and her vein in the arm was in the worst shape. While she was at the hospital, surgeon ordered no blood pressure cuff on the right arm althout they were free to poke her veins there.
Before I read your response, I was thinking maybe her right arm may have more hemolysis because of the bypass creating the extra turbulance.
The technicain used a new butterfly needle each of 3 tries today but maybe we had a case of some sample contamination after it left her body.


I've been taking her to a local lab where the sample collection site and the testing site is in the same building. They just walk the sample over to the lab instead of involving a driver. And the location happens to be really close to our house. Another lab we tried made too many mistakes in handling so we swithced to this lab.

I thought the lab test was done on plasma, not whole blood, but I guess the hemolysis still matters. This is the first time it happened. I was more worried about her INR going down from 2.4. Thanks to good people here I know high INR is better than low INR.

I will take her to the lab tomorrow and will keep you updated.

Thanks again.
EJ
 
I still think it was just a bad test. If it happens again, then maybe there is cause for further investigation. If she's at least 2.0 and no more then 5.0, the risk is very minimal. Certainly better then if she were 1.0.
 
Somebody on the site must be a lab person. From the limited amount of lab work that I have done, I this it was probably mishandling by the lab.
 
Thanks, Al.

I used to work for a director.
People suspected that actually there were a triplet of him (or them) because he was always at work around the clock and everywhere.
People thought that while one is working, the other two were sleeping in the closet (3 shifts / 8 hour shift for each of them). And sometimes all 3 of them would be out showing up at different locations in the building at the same time just to confuse people just for the fun of it.
Now, it seems Ross is everywhere at the same time just like this guy I used to work for :p

Like all of helpful members said, it probably was an isolated incident of mishandled sample. I am hopeful for tomorrow....
 
Marsha,
So far it has been through the lab vein draw.

My insurance (Aetna) customer service at first did not know what I was talking about when I mentioned the home INR monitor. I told her it is like the blood glucose monitor but this one is for people on the blood thinner. She said then it should be covered. She said, for glucose monitor, Aetna sends it directly to members from their warehouse. For INR monitor, it needs to come from the approved suppliers. She was very helpful and nice and gave me the phone numbers of 3 local approved medical suppliers. 1st place I called had been out of business since last December. 2nd and 3rd place did not know what INR monitor was. That was 4 weeks ago.

I was going to work through my insurance thinking we could wait until her level becomes stable. 4 weeks went by and her level has not become stable. I have a friend who is a doctor. He is more impatient and could not wait and a Roche finger-stick monitor is on its way from him. Hopefully it will get here sometime next week.
Then I will have fun time convincing my wife's doctor on its use. Probably need to do it in parallel with the lab test for a while....
 
Before you open the box, be aware that Roche makes two devices approvewd in the USA. One is intended for doctors offices, the other is modified by the manufacturer to meet FDA requirements for non-professional home testing. The strips and controls are the same. HOWEVER, in order to get insurance reimbursement for the device or the supplies, you must have the proper device AND have been trained by an approved trainer. This is mandatory for Medicare and probably for your insurance company. Unfortunately the home device although exactly (sort of) the same is about $600 more expensive.
 
DrAllan,
Thanks for the continued help.
My wife has not shown any of the symptoms you mentioned to suspect the hemolysis to be internal.
I chose the lab carefully to "reduce" the sample handling error. Maybe it reduced it but did not eliminated error. We will see tomorrow and just in case she said she will have it drawn from her ankle/foot instead of the right hand.

For Roche machine, I do not expect to get the insurance reimbursement for this machine and my doctor friend said he is shipping enough strip to last a good while.
I will work on getting the future strips reimbursed when we run out of strips.

Maybe my wife needs a blood count work done to get the current state of hemocrit, etc when we start using Roche machine? Roche machine has a bit narrower hemocrit range than ITC.... I often wondered the variance of home machines vs the lab INR values was maybe partially due to the hemocrit range...

EJ
 
I am coming into this discussion very late, but wanted to tell you that Joe has had hemolysis for a number of years. He is under the care of a hematologist, and gets tested frequently.

There have been times when his lab drawn bloodwork has been mishandled. They sometimes allow the blood to sit around too long, causing clumping of the cells.

His hematologist's group has their own lab machine because they need immediate results. Things are very different when tested on their own machines with a fresh sample.

I don't know if your doctor can order a "stat" test for your wife, but it might make a difference. Also you might want to get the advice of a hematologist.

Joe takes iron twice a day, folic acid prescription strength and Procrit injections (which I give him) three times per week.

Even with all that his bloodwork can be dicey from time to time. Kidney function has something to do with some of the abnormal bloodwork
 
The lab result came back from today's draw: 2.7.
I am so relieved.
Thank you everyone for all the support.
I don't know what I would've done without your help.

Nancy.
The doctor actually gave us a standing "STAT" order for the test.
The first lab was terrible. Often forgot to do "STAT" and when problem happened, their customer service people was worse, making up bogus rules on the fly or lying... Problem in all parts of their chain.
I have make love, not war attitue so it takes a lot to get me worked up, but they had no problem raising by blood pressure each and everytime I spoke to them:mad: . I told even my doctor not to use that lab and eveyone at work. We switched to a new lab for my mental and cardica health.

The new lab, while far from pefect, I have to say is better.
They sometimes forget to do it as a stat but the customer service and even the branch manager will get involved to fix things. They even gave me the direct number of the branch mamanger.
Today's draw was not handled as stat, again. But I checked early enough that they had the manager to go look for the sample and processed it after she found it.


I do not know what happned yesterday. I will check the fax report to see when the report came out when I go home. That will tell me if it was done as STAT.
Hopefully that it is just one time thing of mishandled sample.

I will look into finding a hematologist who has the lab.
It does get tired spending 1 1/2 hours driving/waiting to get it tested in the morning and having to call in the afternoon to check on it each time.
Once I get the home machine, it will be better, but we may have to do parallel testing with lab for a little while.

Does Joe's hematologist office use a portable finger-stick machine like a coaguChek or a full-blown machine like a commercial lab?
 
EJ it might be some time before Nancy replies. Currently Joe is in the hospital and Nancy has been spending all her time with him. Just don't want you to think your being ignored. ;)
 
Actually, Joe's Internist takes care of his Coumadin levels and he uses the finger stick method.

Joe's Hematologist takes care of his blood problems which are abnormal much of the time. His hemaglobin and hematocrit run low, and so do his platelets. He needs transfusions from time to time, and even now, while in the hospital he had a few units of blood, and 6 units of platelets.

It can be a difficult problem and can make other things worse. So it would be a good thing to get a hematologist involved with your wife, at least to get an evaluation on just what her problems are, regarding her blood.

And, by the way, your wife needs a tough advocate for her problems, and it sounds like you will need to be very pushy with whomever is taking care of her. It's a horrible position to be in but I can tell you from my own experiences, it gets easier each time you get after people. Do not be afraid to express your views and get her the help that she needs. If you have to fire some people, then fire them and get someone better. There are times I wish I had a cattle prod---


Is that way too nasty????
 
Nancy said:
I had a cattle prod---


Is that way too nasty????
Click to expand...

Nancy, if you are ever driven to a cattle prod - goodness knows that person is probably way past due for one!!!!!
 
You must log in or register to reply here.

Latest posts

Back
Top