routine hematology
DESCRIPTION
Hemoglobin MeasurementHematocrit MeasurementBlood Cell Counts (RBC, WBC)Preparation and Staining for Blood SmearsErythrocyte Sedimentation RateReticulocyte CountEosinophil CountSickle Cell TestsHEMOGLOBIN MEASUREMENT ProceduresTRANSCRIPT
ROUTINE HEMATOLOGY PROCEDURES
Hemoglobin Measurement
Hematocrit Measurement
Blood Cell Counts (RBC, WBC)
Preparation and Staining for Blood Smears
Erythrocyte Sedimentation Rate
Reticulocyte Count
Eosinophil Count
Sickle Cell Tests
HEMOGLOBIN MEASUREMENT
HEMOGLOBIN MEASUREMENT HEMOGLOBIN: main component of the RBC that
serves as the vehicle for the transportation of oxygen and carbon dioxide.
- It imparts red color to the blood.
- It buffers blood pH.
Purpose of estimating hemoglobin To detect the oxygen carrying
capacity of blood.
The result assists in detecting diseases, which causes a deficiency or excess of hemoglobin.
Studying changes in hemoglobin concentration before or after operations and blood transfusions.
To detect anemia and its severity and to monitor an anemic patients response to treatment.
To check hemoglobin level of blood prior to donating blood.
To calculate red cell indices.
Normal Values
The normal value depends on the age and sex of the individuals:
MALE: 13-18 g/dl FEMALE: 12-16 g/dl AT BIRTH: 15-20 g/dl
Methods of Estimation of Hemoglobin
Colour based (Colorimetric): Based on the colour of hemoglobin or a derivative of hemoglobin.
Physical method (Gravimetric): Based on specific gravity.
Chemical method: Based on iron content of hemoglobin.
Gasometric method: Based on oxygen combining capacity of hemoglobin.
Spectrophotometric method: Based on measurements using spectrophotometric devices.
COLORIMETRIC METHOD:1. Sahli’s Method or Acid Hematin method
Principle
Hemoglobin is converted to acid hematin by N/10 HCl, the resulting brown colour is compared with standard brown glass reference blocks.
The intensity of the brown colour depends on the amount of acid haematin produced, which in turn depends on the amount of hemoglobin in the blood sample.
Reagents:
N/10 Hydrochloric acid (HCl)
Distilled water for dilution.
Blood anticoagulated with EDTA
N/10
Procedure
Place N/10 HCl in the tube up to the lowest mark.
Draw blood up to 20 mm mark in the pipette and transfer it to the acid in the tube.
Rinse the pipette well by drawing up the acid and re expressing it. Mix the acid and blood by shaking the tube well.
Allow it to stand for at least 10 minutes - to allow brown colour to develop due to the formation of acid hematin.
Now dilute the solution with distilled water drop by drop with continuous mixing, using the glass rod provided.
Procedure (contd....) Match the color with
that of the glass plates in the comparator.
Reading is taken when the color of the solution in the tube exactly matches the comparator. Matching should be done at eye level against natural light.
The level of the fluid at its lower meniscus is noted and the reading on the scale corresponding to this level is read as gram/dl.
Sources of Errors
Technical errors
Improper mixing of blood,
Errors in pipetting,
Tissue fluid contaminating capillary blood.
Visual errors – Taking the reading is very subjective, as it is a comparison of colours. It can vary from person to person. So the results may not be accurate.
Quality of the color comparators can affect the reading – If the glass blocks are old or faded it can cause wrong results.
Insufficient time allowed for the conversion of Hb to acid haematin.
A minimum of 10 minutes is required for the reaction to be almost complete, otherwise biological false negative result is obtained.
Carboxyhemoglobin, methemoglobin and sulfhemoglobin are not converted to acid haematin.
Non-hemoglobin substances such as protein, liquid and cell stroma interfere with the colour of blood diluted with acid and hence give false results.
Time delay - The brown colour of acid haematin is not stable, so undue delay in reading the test result is not allowed.
2. Alkaline Hematin method
In this method the Hb is converted to alkali hematin by the addition of N/10 NaOH.
The alkali hematin gives a brown colour that can be read against comparator standards or in a colorimeter.
Apparatus: Photo electric meter with green filter. N/10 NAOH 0.05 ml pipette Standard (Gibson’s and Harrison’s): This is a
mixture of chromium potassium sulphate, cobaltous sulphate and potassium dichromate in aqueous solution. The solution is equal in colour to 1 in 100 dilution of blood containing 16.0 Hb per dl.
Technique: Add 0.05 ml of blood to 4.95 ml of N/10 NAOH.
Mix well and boil for 4 minutes, along with 5 ml standard solution.
Cool quickly in cold water,and match the test against standard using colorimeter using green filter.If the test give too high value add 5.0 ml of water and read again.
Advantage 1) Unlike Sahli’s method, carboxyhemoglobin,
sulfhemoglobin are converted to alkali hematin.
2) Fetal haemoglobin is resistant to denaturation by alkali and this method is used to determine the level of fetal haemoglobin in blood.
Disadvantage The solution of Hb in alkali has to be heated to
ensure complete denaturation.
Note:
Matching should be done within 30 minutes after boiling
Spectrophotometric method
The esimation is based on Beer’s and Lambert’s law ( OD= HGB CONC)
1) Cyanmethemoglobin method
2) Oxyhemoglobin method
Cyanmethaemoglobin method
This is the preferred and the most accurate method for determining the hemoglobin concentration in laboratory.
Principle: ***Blood is diluted in a solution of
potassium ferri cyanide and
potassium cyanide. ***The absorbance of the solution is then measured in a spectrophotometer at a wavelength of 540 nm or in a colorimeter using a yellow-green filter.
Reagents Hemoglobincyanide standard Detergent modified Drabkin’s
solution
Potassium Ferricyanide
Potassium Cyanide
Potassium Dihydrogen Phosphate
(ORIGINALLY, NaHCO3)
Non-ionic detergent/Sterox SE/Triton X-100/Saponin
Distilled water
Procedure
Take 5ml of Drabkin’s solution in a large sized test tube.
Add 20 micro litres of well mixed anticoagulated venous blood.
Rinse the pipette and mix well.
Allow it to stand at room temperature for 3 - 10 minutes.
Absorbance is measured against reagent blank at 540 nm either in a spectrophotometer or in colorimeter.
Advantages All forms of Hb except SHb are readily
converted to HiCN. Direct comparison with HiCN standard
possible. Stability of the diluted sample. Easy to perform the test. Reagents are readily available. The standard is stable.
Disadvantages Potassium cyanide in the solutions is poisonous,
though it is present only in a very low concentration hence the reagents should be handled carefully.
Explosion can occur if undiluted reagents are poured in the sink. Hydrogen cyanide is released by acidification and the gas if it accumulates can result in explosion. Reagents and samples should be disposed along with the running water in the sink.
Increased absorbance not due to hemoglobin may be caused by turbidity due to abnormal plasma proteins, hyperlipemia, high WBC count or fat droplets, and the presence of HbS and Hb C.
FALSE CYANMETHEMOGLOBIN MTD:
presence of turbidity due to.. HIGH WBC COUNT: to correct,
CENTRIFUGE
READ SUPERNATANT HbS and HbC: to correct, DILUTE 1:1 with
H2O result x 2
Lipemic blood: to correct, PREPARE PATIENT’S BLANK (patient plasma + HiCN reagent)
Specific gravity method (Physical method)
Assesses hemoglobin concentration via blood specific gravity.
Mass screening SG of CuSO4: 1.053 (equivalent to
12.5g/dL)
PROCEDURE:
1.Collect blood sample
2.Drop a blood the copper sulfate solution (distance: 1 cm)
3.Observe the activity of the blood
INTERPRETATION: (Within 15 SECONDS describe how the drop of blood behaves in the solution)
MAINTAIN: hgb concentration equals to 12.5 g/dL/13.5 g/dL
FLOAT: <1.053 OR <12.5 g/dL
SINK: >1.053 OR >12.5 g/dL
Chemical methods (estimation of the iron content) The principle is based on the fact that each
molecule of haemoglobin contains 4 atoms of iron or 3.47 grams of hemoglobin.
The iron present is detached from the hemoglobin and measured.
The hemoglobin is calculated by using the formula.
Hb(gm/dl) = Blood iron content in mg/dl blood
3.47
Gasometric methods(Measurement of Oxygen combining capacity)
It is done by using van Slyke apparatus.
The principle is based on the fact that one molecule of O2 binds to each iron atom.
So one molecule of hemoglobin binds 4 molecules of oxygen. Thus oxygen combining capacity thus indirectly measures the amount of Hb.
It is estimated that 1 gram of hemoglobin binds about 1.34 ml of oxygen.
From this the haemoglobin concentration is calculated by using the following formula.
Hb in gm/dl = O2 binding capacity in ml/dl blood
1.34
Quality Control
The important aspect of quality control is to identify those steps in which the likelihood of error is high and to consider ways to minimize that likelihood. Some of the measures followed are:
Duplicating samples.
Hemolysate of known value are run with batches of tests.
Haemoglobin values are compared with other values. For example PCV = 3 x Hb. This is true unless there is marked microcytosis or macrocytosis.
If haemoglobin values are abnormal either too low or high, check peripheral smear to look for other associated abnormalities.
RULE OF THREE
3 X RBC= HEMOGLOBIN
3 X HGB= HEMATOCRIT 3
Apply only to normocytic, normochromic red cells
HEMATOCRIT MEASUREMENT
HEMATOCRIT MEASUREMENT (Packed Cell Volume)
The percentage of the total volume of WB that is occupied by pRBCs when a known volume of blood is centrifuged at a constant speed for a constant period of time.
Relevance:
1. MOST accurate and simplest for detecting presence and degree of anemia or polycythemia.
2. Essential in determination of red cell indices that help in detecting and classifying various types of anemia.
Principle:
GRAVITY/CENTRIFUGAL FORCE:Due to gravity and centrifugal
force, the dense particle settles down.
1. Macromethod CENTRIFUGE: 2000-2300 for 30mins
1st layer: FATTY LAYER: barely visible unless patient is lipemic
2nd layer: PLASMA
3rd layer: BUFFY COAT (1mm: 10,000 WBCs/mm3)
Bottom: PACKED CELLS
WINTROBE TUBE:
Length: 115 mm LEFT RIGHT
Bore: 3 cm 0-100 100-0
ESR HCT
2. Micromethod *Capillary tube: LENGTH: 70-75 mm
BORE: 1 mm
Holds app. 0.05 ml of WB/ 50 uL of blood
*Centrifuge: 10,000-15,000 for 5 mins
Top: PLASMA
2nd: PLATELETS
3rd: LEUKOCYTES
4th: RETICS, nRBCs
5th: MATURE RBCs
BOTTOM: Clayseal (4-6 mm)
RESULTS
Height of packed red cells (mm)
Hematocrit = ------------------------------------------ × 100
Height of packed RBCs and plasma
(i.e, height of blood column)
HCt. = 45/100 × 100 = 45 percent
This means out of 100 volumes or parts ,45 volumes are red cells and 55 volumes are plasma.
3. AUTOMATED METHODS
HCT is COMPUTED.
HCT= MCV X RBC COUNT
Increased PCV
Polycythemia
-Newborns, High altitude, Hypoxia due to lung and heart diseases.
Congestive Heart failure, Burns (loss of plasma), Dehydration, Severe Exercise, Emotional stress
Decreased PCV
All types of Anaemia
Pregnancy (Hemodilution)
Ingestion of large amount of water
BLOOD CELL COUNTS
BLOOD CELL COUNTS
Counting Chambers
1. FUCH’S ROSENTHAL: 4 X 4 X 2
2. SPEIR’S LEVY: 2 X 5 X 4
3. IMPROVED NEUBAUER: 3 X 3 X 2
Red Cell and White Cell Counts
RBC problem: anemia, polycythemia WBC problem: leukocytosis,
leukopenia RBC reference ranges
• Male 4.50 - 6.00 x 106/L (x 1012/L)
• Female 4.0 -5.0 x 106/L (x 1012/L)
WBC reference range• Both 4.5 – 11.0 x 103/L (x 109/L)
DIFFERENCES BETWEEN RBC AND WBC PIPETTE
RBC pipette WBC pipette1) It has a red bead It has a white bead
2) It has graduations up to mark 101
It has graduations up to mark 11
3) Size of bulb is larger Size of bulb is smaller
4) Size of lumen is smaller
Size of lumen is larger
RBC PIPETTE
WBC PIPETTE
Thoma PipetRBC
Aspirate to 0.5 or 1.0
Dilute to 101DF = 200 or
100
WBCAspirate to
0.5 or 1.0Dilute to 11DF = 20 or
10
IMPROVED NEUBAUER HEMOCYTOMETER
Each scale is 3mm wide and 3mm long.
Depth of the chamber is 0.1mm
The whole scale is divided into 9 big squares.
Each square is 1mm long and 1mm wide.
The four corner squares are
further divided into sixteen
smaller squares and are used
for WBC counting.
Four corner squares are
meant for WBC counting.Total = 64
small squares
W
W
W
W
•Central square is divided into 25 medium sized square and are separated by triple line•The medium sized square are further divided into 16 small square(tiny)•The four corner and central square are used for platelet and RBC count.
Counting Rule
Do not count cells touching
Bottom lineRight line This is to avoid
double counting.
Principle
Dilution of blood Sampling of diluted suspension into
measured volume Counting of cell in that volume
FOCUSING
4X to see the general formation of slide.
10X for WBC counting 40X for RBC/Plt. counting
Source of error
False high count False low count Improper mixing
Uneven distribution of cell
Error in pipetting
Error in calculation
Blood taken from area of hemo concentration
Yeast, dirt and leucocyte are counted as RBC
Blood diluted with tissue fluid
Undue delay in counting of cell
Clumping of cell(AIHA)
Uneven distribution of cell
Faulty technique of counting
Improperly standarized counting chamber
*RBC COUNT @ HPO
RBC diluting fluids are ISOTONIC solutions. DILUTION (RBC pipette): 0.5:100 (blood: diluent) =
1:200 RBC count: RBC/mm3= #RBC x Area Correction
Factor (ACF) x Depth Correction Factor (DCF) X Dilution Factor (DF)
= #RBC X 5 X 10 X 200
= RBC X 10,000
SI: x 0.001
RBC Example… Aspirate blood to 0.5, then dilute to 101 DF = 200 Counted 500 erythrocytes in 5 small squares
RBC count: RBC/mm3= #RBC x Area Correction Factor (ACF) x Depth Correction Factor (DCF) X Dilution Factor (DF)
RBC = 500 rbc x 5 x 10 x 200
= 5.00 x 106/mm3 (L)
*WBC COUNT @ LPO WBC diluting fluids are HYPOTONIC SOLUTIONS to
lyse non-nucleated RBCs. Mix for 3 minutes to allow lysis of RBCs. DILUTION: 0.5:10 (Blood:Diluent)= 1:20
*Leukocytosis: Use RBC pipette (1:100 or 1:200) WBC count: WBC/mm3= #WBC x AF x
DCF X DF
= #WBC X 0.25 X 10 X 20
= WBC X 50
SI: x 0.001
WBC Example…
Aspirate blood to 0.5, then dilute to 11 DF = 20 Counted 160 leukocytes in 4 large
squares
WBC/mm3= #WBC x AF x DCF X DF
= #WBC X 0.25 X 10 X 20
= 160 x 0.25 x 10 x 20
= 8.0 x 103/mm3 (L)
** NUCLEATED RBCs are not lysed by WBC diluents. They are then falsely counted as WBCs.
NV: ADULT: ≥5 nRBCs/100 WBC differential
NEWBORN: ≥10 nRBCs/100 WBC differential
CORRECTED WBC COUNT=
PREPARATION AND STAINING FOR BLOOD SMEARS
Types of blood smears: 1. The cover glass smear.
2. The wedge smear.
3. The spun smear. The are two additional types of blood
smear used for specific purposes
1. Buffy coat smear for WBCs < 1.0×109/L and LE cell preparation
2. Thick blood smears for blood parasites
BLOOD SMEAR PREPARATION
Wedge blood smear
Specimen : EDTA blood within 2 to 3 hours & collected to the mark on tube.
Note : May change RBCs morphology such as Spiculated (crenated) cells if :
1. Excessive amount of anticoagulant to specimen
2. Old blood - long standing.
3. Warm environment (room temperature) may hasten changes.
Procedure
Place a drop of blood from mixed sample on a clean glass slide.
Spreader slide using another clean glass slide at 30-40 degree angle.
Control thickness of the smear by changing the angle of spreader slide
Allow the blood film to air-dry completely before staining. (Do not blow to dry. The moisture from your breath will cause RBC artifact.)
STEPS FOR BLOOD FILM PREP
The Thickness of the spread
Notes:1. If the hematocrit is increased, the angle of the
spreader slide should be decreased.2. If the hematocrit is decreased, the angle of
the spreader slide should be increased.
large angle
low HCT
small angle
high HCT
THIN SMEAR
THICK SMEAR
Pressure
Angle
Speed
Size
Characteristics of a Good Smear
1. Thick at one end, thinning out to a smooth rounded feather edge.
2. Should occupy 2/3 of the total slide area.
3. Should not touch any edge of the slide.
4. Should be margin free, except for point of application.
Note: As soon as the drop of blood is placed on the glass slide, the smear should be made without delay. Any delay results in an abnormal distribution of the white blood cells, with many of the large white cells accumulating at the thin edge of the smear.
Size of Blood drop: 2-3 mm Blood from frosted end: 0.25 inch or 1cm End of smear to end of slide: 0.5 inch
(automated spreader)
Common causes of a poor blood smear
1. Drop of blood too large or too small.
2. Spreader slide pushed across the slide in a jerky manner.
3. Failure to keep the entire edge of the spreader slide against the slide while making the smear.
4. Failure to keep the spreader slide at a 30° angle with the slide.
5. Failure to push the spreader slide completely across the slide.
6. Irregular spread with ridges and long tail: Edge of spreader dirty or chipped; dusty slide
7. Holes in film: Slide contaminated with fat or grease
8. Cellular degenerative changes: delay in fixing, inadequate fixing time or methanol contaminated with water.
Examples of unacceptable smears
A: Blood film with jagged tail made from a spreader with a chipped end.
B: Film which is too thick
C: Film which is too long, too wide, uneven thickness and made on a greasy slide.
D: A well-made blood film.
Examples of unacceptable smears
Biologic causes of a poor smear
1. Cold agglutinin - RBCs will clump together. Warm the blood at 37° C for 5 minutes, and then remake the smear.
2. Lipemia - holes will appear in the smear. There is nothing you can do to correct this.
3. Rouleaux - RBC’s will form into stacks resembling coins. There is nothing you can do to correct this.
Notes:1. Although this is the easiest and most popular
methods for producing a blood smear, it does not produce a quality smear.
2. The WBCs are unevenly distributed and RBC distortion is seen at the edges Smaller WBCs such as lymphocytes tend to reside in the middle of the feathered edge.
3. Large cells such as monocytes, immature cells and abnormal cells can be found in the outer limits of this area.
4. Spun smears produce the most uniform distribution of blood cells.
Fixation
To preserve the morphology of the cells, films must be fixed as soon as possible after they have dried.
It is important to prevent contact with water before fixation is complete.
Methyl alcohol (methanol) is the choice, although ethyl alcohol ("absolute alcohol") can be used.
To fix the films, place them in a covered staining jar or tray containing the alcohol for 2-3 minutes.
Staining the film
Romanowsky staining: Romanowsky stains are universally employed for staining
blood films and are generally very satisfactory. There are a number of different combinations of these
dyes, which vary, in their staining characteristics.
1. Wright’s
2. Giemsa: preferred for blood parasites
3. Modified Wright’s-Giemsa
4. Leishman
5. Jenner
6. May-Grunwald
Principle
The main components of a Romanowsky stain are: A cationic or basic dye (methylene blue or its oxidation
products such as azure B), which binds to anionic sites and gives a blue-grey color to nucleic acids (DNA or RNA), nucleoproteins, granules of basophils and weakly to granules of neutrophils
An anionic or acidic dye such as eosin Y or eosin B, which binds to cationic sites on proteins and gives an orange-red color to hemoglobin and eosinophil granules.
pH value of phosphate buffer is very important Blood and BM staining: 6.4-6.8
Malarial parasite staining: 7.2-7.4
Staining procedure
Thin smear are air dried. Flood the smear with stain. Stain for 1-5 min. Experience will indicate the
optimum time. Add an equal amount of buffer solution and mix
the stain by blowing an eddy in the fluid. Leave the mixture on the slide for 10-15 min. Wash off by running water directly to the centre
of the slide to prevent a residue of precipitated stain.
Stand slide on end, and let dry in air.
too acidic suitable too basic
Causes & correction
Too Acid Stain:1. Insufficient staining
2. Prolonged washing time
3. Mounting cover slips before they are dry
4. Too high acidity of the stain
5. Buffer may cause excessive acidophilia
Correction:1. Lengthen staining time
2. Check stain and buffer pH
3. Shorten buffering or wash time
Too Alkaline Stain:
1. thick blood smear
2. prolonged staining
3. insufficient washing
4. alkaline pH of stain components
5. Diluents tend to cause excessive basophilia
Correction :
1) check pH
2) shorten stain time
3) prolong buffering time
Performing A Manual Differential and Assessing RBC Morphology
White Blood Cells.
1. Check for even distribution and estimate the number present (also, look for any gross abnormalities present on the smear).
2. Perform the differential count.
Principle
Red Blood Cells, Examine for:
1.Size and shape.
2.Relative hemoglobin content.
3.Polychromatophilia.
4. Inclusions.
5. Rouleaux formation or agglutination
Platelets.
1.Estimate number present.
2. Examine for morphologic abnormalities.
Procedures
Observations Under ×10 (LPO)
1.Check to see if there are good counting areas available free of ragged edges and cell clumps.
2.Check the WBC distribution over the smear.
3.Check that the slide is properly stained.
4.Check for the presence of large platelets, platelet clumps, and fibrin strands.
Observations Under 40x (HPO): WBC Estimates
Using the × 40 high dry with no oil. Choose a portion of the peripheral smear
where there is only slight overlapping of the RBCs.
Count 10 fields, take the total number of white cells and divide by 10.
To do a WBC estimate by taking the average number of white cells and multiplying by 2000.
Observations Under × 100: Platelet Estimates
1. Use the oil immersion lens estimate the number of platelets per field.
2. Look at 5-6 fields and take an average.
3. Multiply the average by 20,000.
4. Note any macroplatelets.
Platelets per oil immersion field (OIF)
1) <8 platelets/OIF = decreased
2) 8 to 20 platelets/OIF = adequate
3) >20 platelets/OIF = increased
PLATELETS
Observing and Recording Nucleated Red Blood Cells (nRBCs)
If 10 or more nucleated RBC's (NRBC) are seen, correct the White Count using this formula:
Corrected WBC Count =
Example : If WBC = 5000 and 10 NRBCs have been counted
Then 5,000× 100/110 = 4545.50
The corrected white count is 4545.50.
Manual Differential Counts
These counts are done in the same area as WBC and platelet estimates with the red cells barely touching.
This takes place under × 100 (oil) using the zigzag method.
Count 100 WBCs including all cell lines from immature to mature.
Reporting results
Absolute number of cells/µl = % of cell type in differential x white cell count
Observing direction:
Observe one field and record the number of WBC according to the different type then turn to another field in the snake-liked direction*avoid repeat or miss some cells
normal peripheral blood smear
Band neutrophil
Segmented neutrophil
1.Neutrophils Neutrophils are so named because they are not well
stained by either eosin, a red acidic stain, or by methylene blue, a basic or alkaline stain.
Neutrophils are also known as "segs", "PMNs" or "polys" (polymorphonuclear).
They are the body's primary defense against bacterial infection.
Increased neutrophils count (neutrophilia) 1. Acute bacterial infection.2. Granulocytic leukemia.
Decreased neutrophil count (neutropenia)3. Typhoid fever4. Brucellosis 5. Viral diseases, including hepatitis, influenza, rubella, and
mumps.
Segmented neutrophil Band neutrophil
Shift to left Increased bands mean acute infection, usually bacterial.
Shift to right Increased hypersegmented neutrophil.
Eosinophil
The most common reasons for an increase in the eosinophil count are
1. Allergic reactions such as hay fever, asthma, or drug hypersensitivity.
2. Parasitic infection
3. Eosinophilic leukemia
Basophil
Basophils The purpose of basophils is not completely understood.
Basophil counts are used to analyze allergic reactions.
An alteration in bone marrow function such as leukemia may cause an increase in basophils.
Lymphocyte
Lymphocytes
Lymphocytes are the primary components of the body's immune system. They are the source of serum immunoglobulins and of cellular immune response.
Two types of lymphocytes:
1. B lymphocyte : Humoral immunity
2. T lymphocyte : Cellular immunity
Lymphocytes increase (lymphocytosis) in: 1.Many viral infections 2.Tuberculosis. 3.Typhoid fever 4.Lymphocytic leukemia. A decreased lymphocyte (lymphopenia) count of less than 500
places a patient at very high risk of infection, particularly viral infections.
Monocyte
Diseases that cause a monocytosis include:•Tuberculosis•Brucellosis•Malaria•Monocytic leukemia
Notes
1. Do not count cells that are disintegrating
• eosinophil with no cytoplasmic membrane and with scattered granules
• Pyknotic cell (nucleus extremely condensed and degenerated, lobes condensed into small, round clumps with no filaments interconnecting).
• smudge cells
• Basket cells
•smudge cells•Basket cells
**WBC COUNTING:
100 cells: Routine
50 cells: pt WBC ct<1x 109/L
200 cells: >10% eosinophils
>2% basophils
>11% monocytes
Lymphocytes > neutrophils (except in
children)
**Absolute # of cells: RELATIVE X WBC/L
tail body head
BLOOD SMEAR PREPARATIONFOR BLOOD PARASITES
Peripheral Smear Preparation for blood parasites
Peripheral smear examination for malarial parasite is the GOLD-STANDARD in confirming the diagnosis of malaria. THICK AND THIN SMEARS prepared from the peripheral blood are used for the purpose.
STEP 1
Hold the third finger of the left hand and clean it with swab dipped in Savlon or dettol
Step 2
Prick the finger with needle or lancet and allow the blood to ooze out.
Step 3
Take a clean glass slide. Take 3 drops of blood 1 cm from the edge of the slide, take another drop of blood one cm from the first drop of blood
Step 4
Take another clean slide with smooth edges and use it as a spreader...
Step 5
...and make thick and thin smears. Allow it to dry
Prepared Smear
Thick Film
The thick smear of correct thickness is the one through which newsprint is barely visible.
It is dried for 30 minutes and not fixed with methanol.
This allows the red blood cells to be hemolyzed and leukocytes and any malaria parasites present will be the only detectable elements.
Thick smears are therefore used to detect infection, and to estimate parasite concentration. (FOR COUNTING)
Thin Film
Air dry the thin smear for 10 minutes. After drying, the thin smear should be
fixed in methanol. This can be done by either dipping the thin smear into methanol for 5 seconds or by dabbing the thin smear with a methanol-soaked cotton ball.
While fixing the thin smear, all care should be taken to avoid exposure of the thick smear to methanol.
FOR SPECIATION.
THIN FILM THICK FILM
ERYTHROCYTE SEDIMENTATION RATE
ERYTHROCYTE SEDIMENTATION RATE (ESR)
A nonspecific screening test indicative of inflammation
There are two methods of determining ESR: Westergren and Wintrobe
Studies have shown that the Wintrobe method was found to be misleading in some important cases
As a result, the Westergren method is most widely used
Erythrocyte sedimentation rate(ESR)
Rate of settling of RBC from the plasma after the addition of anticoagulant.
Importance of ESR
1. Good index for the presence of hidden carcinoma but active diseases.
2. It measures the suspension stability of RBC.
3. It measures the abnormal concentration of fibrinogen and serum globulin.
Roleaux formation
(Packing or piling of RBC)
ERYTHROCYTE SEDIMENTATION RATE (ESR)
Anticoagulated blood is drawn up into a tube of standardized dimensions and left in a vertical position for exactly one hour.
This test measures the distance that RBCs will fall in a vertical tube over a given time period
It is used as an initial screening tool and also as a follow-up test to monitor therapy and progression or remission of disease. The ESR is directly proportional to red cell mass
The ESR is reported in millimeters/hr
ERYTHROCYTE SEDIMENTATION RATE (ESR)
3 STAGES:
1. LAG PHASE: (10 mins) the red cells form a characteristic rouleaux pattern and sedimentation is generally slow.
2. DECANTATION PHASE: (40 mins) sedimentation accelerates.
3. FINAL PACKING PHASE: (10 mins) as red cell aggregates pile up at the base of the tube
ERYTHROCYTE SEDIMENTATION RATE (ESR)
The size of the rouleaux aggregates formed in the Lag Phase is the critical factor affecting the final result of the ESR.
The rouleaux itself appears to be influenced mainly by certain plasma proteins including FIBRINOGEN, IgM AND ALPHA2-MACROGLOBULIN.
Methods
A. Wintrobe and landsberg method Anticoagulant used- Ammonium potassium
oxalate (wintrobe solution/ double oxalate/balanced oxalate/ paul-Heller’s soln.)
Tube – wintrobe tube
- Left side – RED (for ESR: 0-100)
- Right side – WHITE ( for hematocrit: 100-0)
Procedure
1. With a long stem pasteur pipet, fill the wintrobe tube with oxalated blood up to 0 mark.
2. Let the wintrobe tube stand perfectly vertical.
3. Read result after 1 hour. Reading must be done on the left red side of the tube.
Normal values Male - (0-9) mm/hr Female - ( 0-20 )mm/hr Children- (0-13) mm/hr
White 10
Red 0
Red cells
0 at bottom at bottom 10
Layers -Plasma layer-Buffy coat (WBC and platelets)-Packed RBC (hematocrit)
Wintrobe tube
B. Original Westergren method (200mm) – most sensitive and most accurate.
- Anticoagulant used -3.8% sodium citrate
- Tube- westergren tube (through suction method long tube)
200 mm
0
Procedure
1. Fill the tube with the citrated blood
2. Stand the tube vertically and read result at the end of 1 hour.
Normal values
MALE: <50 y/o: 0-15 mm/hr
>50 y/o: 0-20mm/hr
FEMALE: <50 y/o: 0-20 mm/hr
>50 y/o: 0-30mm/hr
CHILDREN: 0-10 mm/hr
Wintrobe Westergren
Bore 3 mm 2.5 mm
Graduation up to 100 mm
up to 200 mm
Anticoagulant Double oxalate
3.8% sodium citrate
Amount of blood
1 ml 2.4 ml
Reading once Twice
Hematocrit
FACTORS AFFECTING ESR
1. Intrinsic Factor
- nos of RBC ( less RBC faster settlement)
- size of RBC ( Bigger the size is faster the settlement)
- viscosity of Plasma ( less viscous fast settlement)
* nos of RBC- inversely
* size of RBC- directly
2. Extrinsic factor Length of tube ( smaller length fast
settlement) Diameter of tube (wider diameter fast
settlement) Position of tube(vertical or slightly fast
settlement Temperature ( high temp. fast settlement) Pipetting ( incorrect pipetting result error) Volume of blood ( less blood faster settle.) Anticoagulant (more anticoagulant slow
settlement)
PATHOLOGICAL CONDITIONS ASSOCIATED WITH ESR
Increased ESR
1. Kidney disease
2. Pregnancy
3. Rheumatic fever
4. Rheumatoid arthritis
5. Anemia
6. Syphilis
7. Systemic lupus erythematosus
8. Thyroid disease
9. Elevated room temperature
10. Ischemic stroke
11. Temporal arteritis
PATHOLOGICAL CONDITIONS ASSOCIATED WITH ESR
Decreased ESR
1. Congestive heart failure
2. Hyperviscosity
3. Decreased fibrinogen levels
4. Polycythemia
5. Sickle cell anemia
< 0.5 mm/hr
RETICULOCYTE COUNT
RETICULOCYTE
The reticulocyte is the cell stage immediately before the mature erythrocyte.
This cell spends 2 to 3 days maturing in the bone marrow before it is released into the peripheral circulation, where it spends an additional day of maturation.
Acidophilic erythroblast (NRBC) expels the nucleus and becomes the reticulocyte
Bone marrow macrophages phagocytize and digest the expelled nucleus.
The size of reticulocyte is about 8 μm
RETICULOCYTEThe reticulocyte count is the most effective measure
of erythropoietic activity.
Reticulocyte counts are a reflection of bone marrow health or injury
Reticulocytes are red cells that are non-nucleated and that contain remnant RNA material, reticulum.
To be counted and evaluated, reticulocytes must be stained with supravital stains, like new methylene blue or brilliant cresyl blue.
RETICULOCYTE
Because the bone marrow has the capacity to expand its production up to 7 times the normal rate, an elevated reticulocyte count or reticulocytosis is the appropriate response in anemic stress
Reticulocytes will be seen in the peripheral smear as polychromatophilic macrocytes (large, bluish cells)
Nucleated red blood cells may also be visualized in the peripheral smear as the bone marrow races to deliver cells prematurely at a rapid rate.
RETICULOCYTE COUNT
Procedure (Supravital Staining)1. Mix 4 drops of New Methylene Blue with 4 drops of patient’s blood.
2. Let the specimen mix for 10 to 15 minutes. Make a wedge smear and let it air dry. Label the smear
3. Allow the smear to completely dry and read under the microscope using x100 oil immersion.
4. Count the number of reticulocytes in 1000 cells (10 fields).
**To be considered a retic, it must contain 2 or more blue-staining particles (reticulum)
RETICULOCYTE
Number of Retic = (# retic per 1000 red cells x 100)/1000Note: 1000 red cells = 10 fields
Example: 35 x100/1000 = 3.5%
OR
Number of retic counted divided by 10
Example; 35/10 = 3.5 %
RETICULOCYTE
RETICULOCYTE
Normal Values
Adults: 0.5% to 1.5%
Infants: 2.0% to 6.0%
RETICULOCYTE
Limitations1. Recent blood transfusion can interfere with accurate reticulocyte results.
2. Mishandling, contamination, or inadequate refrigeration of the sample can interfere and cause inaccurate test results.
3. Red cell inclusions such as Heinz bodies, siderocytes, and Howell-Jolly bodies can be mistaken for reticulocytes. If these are counted as reticulocytes, they will falsely increase the reticulocyte count. Inclusions should be confirmed with Wright’s stain
RETICULOCYTE
Increased Reticulocyte countIncreased reticulocyte counts indicate increased erythropoietic activity usually as the bone marrow compensates in response to anemic stress
Increased count associated with:
1. Rapid blood loss
2. High elevation
3. Hemolytic anemias
4. Medications such as levodopa, malarial medications, corticotrophin, and fever-reducing medications
5. Pregnancy
RETICULOCYTE
Decreased Reticulocyte count (<0.5%)
Low reticulocyte counts indicate decreased erythropoietic activity
Decreased count associated with:
1. Aplastic anemia (where the production of either white or red cells or both is seriously impaired)
2. Exposure to radiation or radiation therapy
3. Chronic infection4. Medications such as chloramphenicol, methotrexate and other chemotherapy medications5. Untreated pernicious anemia/megaloblastic anemia
RETICULOCYTE
Calculation of corrected reticulocyte
The reticulocyte count is most often expressed as a percentage of total red cells.
In states of anemia, the reticulocyte percentage is not a true reflection of reticulocyte production.
A correction factor must be used so as not to overestimate marrow production
Because each reticulocyte is released into whole blood containing few RBCs and a low hematocrit (Hct), the percentage of reticulocyte will be increased.
RETICULOCYTE
Calculation of corrected reticulocyteThe corrected reticulocyte count may be calculated
by the following formula:
Corrected reticulocyte count = (Retic % x patient’s Hct %) divided by Average normal Hct
Note: Average normal Hct is 45%.
Example: Uncorrected retic % = 5.0%Patient Hct = 35.0% (male)Average normal hct for male = 45%
Corrected retic % = (5.0% x 35%) / 45 = 3.89%
Corrected retic % = 175/45 = 3.89 %
Calculation of reticulocyte production index (RPI)
general indicator of the rate of erythrocyte production increase above normal in anemias.
indicated BM response to anemia
RPI= CRC ÷ maturation time of retics in the blood NV: 1 (Hct: 45%)
**maturation time of retics in blood1 day= Hct: 45 ± 5%1.5 days= Hct: 35 ± 5%2 days= Hct: 25 ± 5%2.5 days= Hct: 15 ± 5%
RPI >3 RPI <2Adequate response of BM to anemia
Inadequate response of BM to anemia
- Chronic hemolysis - Aplastic anemia
- Recent hemorrhage - Ineffective erythropoiesis (megaloblastic anemia)
- Response to therapy
EOSINOPHIL COUNT
EOSINOPHIL COUNTNV: 50-350 x 109/L
Allergic reactions
Hyperadrenalism (Cushing’s disease)
Parasitic infections
Shock
Brucellosis Ff. administration of ACTH
Certain leukemias
2 METHODS:
1. INDIRECT: WBC x %eos
2. DIRECT: most widely used
DILUTING FLUID:
- Phloxine/Eosin/Neutral red iodide: stain EOS red.
- Propylene glycol: lyses RCs
- Na2CO3: lyse WBCs except eos.
- Heparin: prevents clumping
**Fuch’s Rosenthal counting chamber: recommended
THORN’S TEST
assesses adrenocortical function
EO Ct #1: FASTING
EO Ct #2: 4 hours after administration of ACTH (normally, )
NORMAL: EO Ct #1 > EO Ct #2 lower by 50%
HYPOADRENALISM: EO Ct #1 = EO Ct #2
SICKLE CELL TESTS
A. SODIUM METABISULFITE METHOD
*WB + Sodium metabisulfite (strong RA) SICKLING (maximal at 37
@HPO after 1 hour to 24 hours at room temperature.
POSITIVE: presence of holly-leaf form (sickle cell)
B. SOLUBILITY TEST
- uses 12x 75mm test tubes
- tubes are approximately 1 inch in front of the lined reader scale.
*RBCs + saponin (lyses RBCs) Hgb S forms liquid crystals causing turbidity.
POSITIVE: turbid, lines are not visible
NEGATIVE: solution remains clear
FALSE (+) FALSE (-)- Inc
immunoglobulins- Use of 10x75 mm
test tube- Lipemia - <7 g/dl hgb- Inc WBCs
END