Check clotting in

• Selected babies with evidence of bleeding or who are at high risk of disseminated intravascular coagulation (DIC) e.g. severe sepsis or NEC 
• Babies receiving therapeutic hypothermia 
• Metabolic disease: urea cycle disorder, galactosaemia, tyrosinaemia, organic acidaemia
• Significant liver dysfunction or conjugated jaundice
• Babies undergoing surgery or tissue biopsy who have had previous bleeding problems
• Family history of inherited bleeding disorder (after discussion with consultant haematologist)
• Thrombocytopenia (see Thrombocytopenia guideline)

Sampling

• Ensure sample from a free-flowing vein (peripheral or umbilical) or from an arterial line before heparinising
• Fill exactly to black mark on tube (usually 1.3 mL)
• If sample clots (this does not confirm normal coagulation), repeat
• If sampling from arterial line with heparin infusion, take larger volume (e.g. 2.5 mL) from dead-space (see Arterial line sampling guideline) 

Request

• INR (measure of PT)
• APTT
• Fibrinogen
• If features of DIC (e.g. bruising, bleeding, sepsis), request fibrin degradation products and D-dimer (if available)
• If concerned/unsure about initial results, seek senior advice

Normal values

Note 

• Normal values vary greatly between sources. Few sources give values for preterm babies 
• Coagulopathy defined as PT or APPT >1.5 x midpoint of normal range 

• No evidence to support the use of FFP to try to correct abnormalities of coagulation screening alone in non-bleeding babies 
• FFP may be of benefit to babies with clinically significant bleeding (including massive blood loss) or before invasive procedures with a risk of significant bleeding, if they also have an abnormal coagulation profile defined as a PT or APTT significantly above normal gestation or postnatal age-related reference range (see Table)
• In inherited clotting factor deficiencies, use FFP only when pathogen inactivated factor unavailable. Discuss with consultant haematologist before giving FFP
• If INR alone is raised (>2), and clotting samples were performed before first dose of vitamin K, repeat clotting screen. If sample taken after first dose of vitamin K, repeat dose (see Vitamin K guideline)
• If APTT raised and active bleeding give FFP 10–20 mL/kg over 30–60 min 

Cryoprecipitate

• Indicated for hypofibrinogenaemia (fibrinogen level <0.8–1.0 g/L) either congenital or secondary to DIC/sepsis WITH bleeding
• Give 5–10 mL/kg over 30–60 min

• Repeat coagulation profile 2–4 hr after FFP/cryoprecipitate 
• Give further treatment only if bleeding persists – do not treat abnormal clotting screen in the absence of bleeding
• If abnormal coagulation persists for >24 hr in the absence of any precipitating factors, seek advice from haematologist