Thromborel® S

Revision bar indicates update to previous version.

Human thromboplastin containing calcium

Intended Use
Thromborel® S Reagent is used for the determination of the prothrombin time (PT) according
to Quick and, in conjunction with the relevant deficient plasmas, for the determination of the
activity of coagulation factors II, V, VII and X.

Summary and Explanation

The prothrombin time measured with Thromborel® S Reagent is a rapid, sensitive screening
test for coagulation disorders in the domain of the extrinsic system (Factors II, V, VII and X).
Due to its high sensitivity for these coagulation factors Thromborel® S Reagent is especially
well suited for:
– The induction and monitoring of oral anticoagulant therapy with vitamin K antagonists1‑3.
– Diagnosing genetically caused deficiencies in coagulation factors of the extrinsic system.
– Diagnosing acquired deficiencies in coagulation factors.
– Checking the synthesis performance of the liver in hepatic diseases.
With Thromborel® S Reagent and the relevant deficient plasma, it is possible to determine the
activity of coagulation factors II, V, VII and X.
Additionally, various photo-optical coagulation analyzers are able to derive the fibrinogen
value from the determination of the prothrombin time.

Principle of the Method

The coagulation process is triggered by incubation of plasma with the optimal amount of
thromboplastin and calcium. The time to formation of a fibrin clot is then measured.

Reagents
Note
Thromborel® S Reagent can be used manually or on automated coagulation analyzers.
Siemens Healthcare Diagnostics provides Reference Guides (Application Sheets) for several
coagulation analyzers. The Reference Guides (Application Sheets) contain analyzer/assay
specific handling and performance information which may differ from that provided in these
Instructions for Use. In this case, the information contained in the Reference Guides
(Application Sheets) supersedes the information in these Instructions for Use. In addition,
please also consult the instruction manual of the instrument manufacturer!
Materials provided
10 x 4 mL, REF OUHP29
10 x 10 mL, REF OUHP49, REF 10484202
Each pack of Thromborel® S contains a table of lot- and analyzer-specific ISI values.

OUHPG29C11 Rev. 10 – en 2018-08 1/6

Thromborel® S

Composition
Thromborel® S Reagent: lyophilized human placental thromboplastin (≤ 60 g/L), calcium
chloride (approx. 1.5 g/L), stabilizers
Preservatives: gentamicin (0.1 g/L),
5-chloro-2-methyl-4-isothiazol-3-one and
2-methyl-4-isothiazol-3-one (< 15 mg/L)
Warnings and Precautions
For in-vitro diagnostic use only.
Warning! Thromborel® S
H317: May cause an allergic skin reaction.
P280, P272, P302 + P352, P333 + P313, P501: Wear protective gloves/protective
clothing/eye protection/face protection. Contaminated work clothing should not be
allowed out of the workplace. IF ON SKIN: Wash with plenty of soap and water. If skin
irritation or rash occurs: Get medical advice/attention. Dispose of contents and
container in accordance with all local, regional, and national regulations.
Safety data sheets (MSDS/SDS) available on www.siemens.com/diagnostics.
Thromborel® S Reagent is prepared from human placenta. During the manufacturing
process, steps are taken to remove and/or inactivate any viruses which may be
present. Nevertheless, since absence of infectious agents cannot be proven, all
materials obtained from human tissue or body fluids should always be handled with
due care, observing the precautions recommended for biohazardous material.

Reagent Preparation
Reconstitute Thromborel® S Reagent with the amount of distilled or deionized water stated on
the vial label and mix well by inverting the vial 8 to 10 times, then warm the reagent to 37 °C
before use. Please note: after reaching 37 °C the reagent must be incubated at this
temperature for 30 minutes. If a water bath is used a total incubation time of 45 minutes is
recommended. Before use the reagent should be mixed carefully.
Storage and Stability
Store Thromborel® S Reagent unopened at 2 to 8 °C and use by the expiry date given on the
label.
Stability after reconstitution:
at 37 °C 8 hours (opened vial)
at 15 to 25 °C 2 days (opened vial)
at 2 to 8 °C 5 days (closed vial)
Information about on-board stability is specified in the Reference Guides (Application Sheets)
for the different coagulation analyzers.
Note on reagent expiration: Control values outside the assigned range for the control used
(e.g., Control Plasma N) are an indicator of reagent expiration.
Materials required but not provided
Control Plasma N or Dade® Ci-Trol® Level 1
Control Plasma P, Dade® Ci-Trol® Level 2 or Dade® Ci-Trol® Level 3
PT-Multi Calibrator (Refer to the Instructions for Use for details on use)
Standard Human Plasma or fresh normal plasma3 for determining the reaction time of normal
plasma
Sodium citrate solution (0.11 mol/L, 3.2 %) for blood collection
Distilled or deionized water without preservatives
Plastic tubes

2/6 2018-08 OUHPG29C11 Rev. 10 – en

 Thromborel® S

Plastic transfer pipettes

Pipettes for precise measurement of 10.0 mL, 1.0 mL, 0.20 mL and 0.10 mL
Coagulation analyzer

Specimen Collection and Preparation

Carefully mix 1 part sodium citrate solution (0.11 mol/L) with 9 parts venous blood, avoiding
the formation of foam.
Centrifuge the blood specimen at 1500 x g for no less than 15 minutes at room temperature.
Store in an unopened tube at room temperature. Do not store on ice or at 2 to 8 °C as cold
activation of F VII may alter results.
Plasma should be tested within 24 hours of blood collection. Samples should not stand at
37 °C for more than five minutes. If the patient is on both heparin and coumarin-based
anticoagulant therapy, the results may vary with time of storage.
Please refer to CLSI document H21-A5 for detailed information on sample preparation and
storage4.

Procedure
Manual Testing:
Pipette into a test tube prewarmed to 37 °C
Citrated plasma 100 µL
Incubate for 1 minute at 37 °C
Thromborel® S Reagent (warmed to 37 °C) 200 µL
On addition of Thromborel® S Reagent start stop-watch or timer on the coagulation analyzer and determine the
coagulation time.

Internal Quality Control

Normal range: Control Plasma N or Dade® Ci-Trol® Level 1
Therapeutic range: Control Plasma P, Dade® Ci-Trol® Level 2 or Dade® Ci-Trol® Level 3
Two levels of quality control material (normal and pathological range) have to be measured at
start of the test run, with each calibration, upon reagent vial changes and at least every eight
hours on each day of testing. The control material should be processed as a sample. Each
laboratory should establish its own QC ranges based on the assigned values and ranges
provided by the control manufacturer or based on values determined by the laboratory.
If control values are recovered outside the defined range, check the instrument, reagent and
calibration for problems. Do not release patient results until the cause of deviation has been
identified and corrected.

Results
The results can be reported in seconds, in % of norm, as prothrombin ratio (PR) or as
International Normalized Ratio (INR). Monitoring of oral anticoagulant therapy with vitamin K
antagonists should only be reported with PT results expressed as INR as recommended in
official guidelines and in the literature3.
To obtain the prothrombin ratio, the reaction time of the sample is divided by the reaction
time of the normal plasma pool (e.g., Standard Human Plasma):
Reaction time of sample (seconds)
PR =
Reaction time of normal plasma (seconds)
If the prothrombin ratio is determined using a normal plasma which does not have a PR of 1.0,
the PR of this plasma has to be taken into account in the calculation:

OUHPG29C11 Rev. 10 – en 2018-08 3/6

Thromborel® S

Reaction time of sample (seconds) x PR of normal plasma

PR =
Reaction time of normal plasma (seconds)
The prothrombin ratio can be converted into internationally comparable values by means of
the International Sensitivity Index (ISI). The result obtained is in International Normalized Ratio
(INR): INR = PRISI
Thromborel® S Reagent is calibrated against the international reference thromboplastin
preparations in test runs on normal plasmas and plasmas of donors on oral anticoagulants in
the stable phase. The ISI value for Thromborel® S Reagent is stated in the lot-dependent Table
of Assigned Values.
Establishment of the Reference Curve in % of norm
Refer to the Reference Guide (Application Sheet) for your analyzer for calculation using % of
norm.
Derived Fibrinogen
Using Thromborel® S Reagent and the appropriate assay on Siemens photometric coagulation
analyzers or SYSMEX coagulation analyzers, the fibrinogen concentration may be derived by
analyzing the change in optical signal during prothrombin time determinations, using a
derived fibrinogen calibration curve. This calibration curve (master curve) is provided in the
lot-dependent Table of Assigned Values.

Limitations of the Procedure

Normal samples spiked with heparin concentrations exceeding 0.6 U/mL produced abnormal
results. However, Thromborel® S Reagent may be used to monitor the administration of
overlapping dosages of heparin and oral anticoagulants. Inhibitors of the Lupus type
anticoagulant can influence prothrombin time and lead to INRs that do not accurately reflect
the true level of anticoagulation5.
Lipoglycopeptide antibacterial drugs (such as oritavancin or telavancin) may interfere with PT
based assays. Consult Instructions for Use of respective drugs.
The choice of anticoagulant (i.e. oxalate instead of citrate) and the condition of the specimen
(e.g hemolyzed, lipemic, parenteral feeding, etc.) may affect results of PT and derived
Fibrinogen. The latter is particularly true for PT measurements done with optical instruments.
Hirudin or other direct thrombin inhibitors in therapeutic dose result in prolonged
prothrombin times6‑8.
Derived fibrinogen results within the reference interval can be directly reported. Results
outside the reference interval should be re-measured by a standard fibrinogen determination
method, e.g. Fibrinogen method with Dade® Thrombin Reagent or with Multifibren® U
reagent. Derived fibrinogen testing is not suitable in patients with dysfibrinogenemia9 or
patients with prolonged PT, e.g. under oral anticoagulation10,11. In thrombolysis therapy,
derived fibrinogen and fibrinogen determination according to Clauss may deviate and should
be considered in therapy control. Blood plasma substitutes that contain hydroxyethyl starch
(HES) may interfere with the analysis. Therefore, it is advised that plasma samples that contain
such substitutes should not be analyzed with the PT derived fibrinogen method.
Siemens has validated use of these reagents on various analyzers to optimize product
performance and meet product specifications. User defined modifications are not supported
by Siemens as they may affect performance of the system and assay results. It is the
responsibility of the user to validate modifications to these instructions or use of the reagents
on analyzers other than those included in Siemens Application Sheets or these Instructions for
Use.
Results of this test should always be interpreted in conjunction with the patient’s medical
history, clinical presentation and other findings.

4/6 2018-08 OUHPG29C11 Rev. 10 – en

 Thromborel® S

Expected Values
Values for healthy individuals vary from laboratory to laboratory depending on the technique
used. Therefore, each laboratory should establish its own reference intervals based on the
procedure and coagulation analyzers used.
In studies on the SYSMEX CA-7000 System with ostensibly healthy subjects the following
reference intervals (2.5th to 97.5th percentile) were determined:

Analyte Samples n = 2.5th to 97.5th percentile

PT 158 9.8–12.1 seconds

Derived fibrinogen 124 1.7–3.2 g/L
PT (% of norm)12 70–130 %

Therapeutic Ranges
Therapeutic ranges for INR may vary depending on the indication of oral anticoagulant
therapy2.

Performance Characteristics
Precision
The precision of the PT determination is highly dependent on the method used. The precision
of Thromborel® S Reagent on the BCT® System was estimated by assaying normal and
pathological control plasmas over a five day period, one run per day in replicates of eight. In a
study the within-run precision ranged from 0.7 to 1.2 %, and the inter-assay precision ranged
from 1.5 to 2.2 %.
Method Comparison
A comparison of Thromborel® S Reagent with the British Comparative Thromboplastin yielded
a correlation coefficient of 0.979, with good numerical agreement of the values in percent of
norm13.

References
1. Quick AJ, Stanly-Brown M, Bancroft FW. A study of the coagulation defect in hemophilia
and in jaundice. Am J Med Sci. 1935;190:501-11.
2. Ansell J, Hirsh J, Hylek E, et al. Pharmacology and management of the vitamin K
antagonists. Chest. 2008; 133:160S-198S.
3. Poller L. The prothrombin time. WHO/LAB/98.3. 1998.
4. CLSI. Collection, Transport, and Processing of Blood Specimens for Testing Plasma-Based
Coagulation Assays and Molecular Hemostasis Assays; Approved Guideline – Fifth Edition.
CLSI document H21-A5 (ISBN 1-56238-657-3). CLSI, 940 West Valley Road, Suite 1400,
Wayne, Pennsylvania 1908781898 USA, 2008.
5. Tripodi A, Chantarangkul V, Clerici M, et al. Laboratory control of oral anticoagulant
treatment by the INR system in patients with the antiphospholipid syndrome and lupus
anticoagulant. Results of a collaborative study involving nine commercial thromboplastins.
Br J Haematol. 2001;115:672-8.
6. Tobu M, Iqbal O, Messmore HL, et al. Influence of different anticoagulant agents on
fibrinopeptide A generation. Clin Appl Thromb Hemost. 2003;9:273-92.
7. Fenyvesi T, Joerg I, Harenberg J. Influence of Lepirudin, Argatroban, and Melagatran on
prothrombin time and additional effect of oral anticoagulation. Clin Chem.
2002;48:1791-4.
8. Tobu M, Iqbal O, Hoppensteadt D, et al. Anti-Xa and anti-IIa drugs alter International
Normalized Ratio measurements: Potential problems in the monitoring of oral
anticoagulants. Clin Appl Thromb Hemost. 2004;10:301-9.

OUHPG29C11 Rev. 10 – en 2018-08 5/6

Thromborel® S

9. Llamas P, Santos AB, Outeiriño J, et al. Diagnostic utility of comparing fibrinogen Clauss
and prothrombin time derived method. Thromb Res. 2004; 114: 73-4.
10. Wagner C, Dati F. Fibrinogen. In: Thomas L, ed. Clinical Laboratory Diagnostics. Frankfurt:
TH-Books Verlagsgesellschaft; 1998:609-12.
11. De Cristofaro R, Landolfi R. Measurement of plasma fibrinogen concentration by the
prothrombin-time-derived method: applicability and limitations. Blood Coagul Fibrinolysis.
1998 Apr;9(3):251-9.
12. Wagner C, Dati F. Prothrombin time (PT) test. In: Thomas L, ed. Clinical Laboratory
Diagnostics. Frankfurt: TH-Books Verlagsgesellschaft; 1998:599-601.
13. Barthels M, Bruhn HD, Duckert F, et al. Bestimmung der Thromboplastinzeit mit einem
neuen standardisierten Thromboplastin aus menschlicher Plazenta: Ergebnisse einer
kooperativen Studie. J Clin Chem Clin Biochem. 1987;25:267-80.

Definition of Symbols

Do not reuse YYYY-MM-DD Use By

LOT Batch Code REF Catalogue Number

Caution, consult accompanying
Manufacturer
documents
Authorized representative in the
EC REP Contains sufficient for <n> tests
European Community

Biological Risks IVD In Vitro Diagnostic Medical Device

Temperature Limitation Consult instruction for Use

Non-sterile CE mark

CONTENTS Contents Reconstitution volume

LEVEL Level Keep away from sunlight and heat

SYSMEX is a trademark of SYSMEX CORPORATION.

BCT, Ci-Trol, Dade, Multifibren and Thromborel are trademarks of
Siemens Healthcare Diagnostics.

© 2010 Siemens Healthcare Diagnostics Products GmbH.

All rights reserved.

Siemens Healthcare Diagnostics Products GmbH Siemens Healthcare Headquarters

Emil-von-Behring-Str. 76 Siemens Healthcare GmbH
35041 Marburg/Germany Henkestraße 127
91052 Erlangen/Germany
Phone: +49 9131 84-0
siemens.com/healthcare

6/6 2018-08 OUHPG29C11 Rev. 10 – en