CLS500 Routine Hematology Tests

Linda Sykora
lmsykora@unmc.edu

Routine Hemo Tests Objectives

Discuss specimen requirements, reference ranges
and significance of the following tests:
Complete Blood Count (CBC)

WBC count
RBC count
Hemoglobin
Hematocrit
RBC Indices (MCV, MCH, MCHC, RDW)
Platelet count

Differential
WBC differential and cell morphology

Reticulocyte count
Erythrocyte Sedimentation Rate (ESR)
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Routine Hemo Tests Objectives

Routine Hematology Tests

Describe prepre-analytical errors, i.e., specimen

collection errors that can cause inaccurate results.

All tests have institutioninstitution-established reference

ranges
Normal
Normal varies with age, sex, altitude and/or testing
method

Discuss quality control and checks utilized to

establish test validity and prevent erroneous
laboratory results.

Tests included in the CBC & Differential are the

most frequently requested

Evaluate CBC and Differential results to detect

the presence of a Hematologic disorder or
associated condition:

A battery of cell count measurements

EDTA anticoagulated whole blood

Recognize deviations from normal blood cell

concentrations for age and sex
Identify significant abnormalities in cellular morphology
Correlate results with clinical information to guide
further testing

Testing is automated or done manually (e.g

(e.g,,
microscopic exam of blood smear) to verify
automated results
Manual testing delays test TAT

Potential sources of error

Potential sources of error

Control samples with known values are used to
check result reliability

The most fundamental responsibility of a

laboratory is to ensure quality test results.
PrePre-analytical errors are the most common cause
of inaccurate results
Testing process begins with sample collection

Critical values are confirmed, called &/or redrawn

Patient results are compared to previous results
Flagged
Flagged or inconsistent data is verified

Wrong patient ID or tube labeling

Partially clotted blood or hemolysis
Hemodilution or hemoconcentration
Wrong tube drawn or insufficient fill
Improper handling

Do controls detect specimen collection errors?

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CLS500 Application and Interpretation

of Clinical Laboratory Data
Hematology Tests Powerpoint Handout

Controls detect invalid results caused by errors

in testing technique, reagents or instrument
malfunction

Checks done to prevent erroneous results:

Collection errors must be recognized:

WBC Count

Adult CBC

WBC count - total # of white cells reported in

thousands/uL
thousands/uL;; does not distinguish WBC types
4-11 K/uL
x3=15.1

11-17 g/dL

x3=45.0
RBC
Parameters

=RBC
size

82-98 fL
RBC
Indices

Significance
WBC count
count.Leukopenia
Decreased production, increased use

WBC count
count.Leukocytosis
Increased production, shift/pseudo

>150 K/uL
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Critical values: WBC<1.0 or >40.0 K/uL

K/uL

RBC Count, HGB, HCT

RBC Count, HGB, HCT

RBC count total # of red cells reported in

millions/uL
millions/uL
Hemoglobin - photometric measurement of Hgb
concentration in red cells reported in g/dL
Corrected Hgb value if lipids or bilirubin interfere

Significance

Hematocrit percentage (%) of red cells in a

known volume of whole blood

RBC, HGB and/or HCT values

values.Anemia
Decreased production, increased loss/destruction

RBC, HGB and/or HCT values

values.Polycythemia

Automated or manual method in which the blood

is centrifuged into layers

Increased production, fluid loss

Critical values: HGB <7.0 or >18.5 g/dL

RBC count, HGB and HCT measurements

parallel each other
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Relationship: HGB x 3 = HCT if red cells are

normal in size and hgb content

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RBC Indices

Evaluation:

Define size and/or hgb content of red cells

Include:

3 adults

MCV, mean cell volume

MCH, mean cell hemoglobin
MCHC, mean cell hemoglobin concentration
RDW, red cell distribution width

Used to classify anemia

anemia.MCV most useful
Normocytic RBCs

(1) All parameters are normal

(2) Leukocytosis, severe anemia
(3) Polycythemia

Small
lymph
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CLS500 Application and Interpretation

of Clinical Laboratory Data
Hematology Tests Powerpoint Handout

Microcytic RBCs

RBCs are smaller

Macrocytic RBCs

RBCs are larger

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RBC Indices

RBC Indices

MCV = average RBC size, varies with age

MCHC = average hgb concentration per RBC

Normal adult MCV 8282-98 fL = normocytic red cells

MCV <82 fL = microcytic red cells
MCV >98 fL = macrocytic red cells
Normal newborn ~110 fL;
fL; normal children ~77 fL

Normocytic RBCs
MCV 8282-98 fL

Microcytosis
MCV <82 fL

Normal 3232-36% = normochromic red cells

MCHC <32% = red cells may be hypochromic

RDW = index of RBC size variation

Normal 1010-14% (low RDW) = uniform RBC size
A high RDW >14% is caused by variations in RBC size
called anisocytosis

Macrocytosis
MCV >98 fL

Indices are average values so have less meaning

in heterogeneous RBC populations
A normal MCV value with a high RDW >22% may not
mean the red cells are normocytic if wide RBC size
variations are present, i.e., microcytes,
microcytes, normocytes
and/or macrocytes

MCH varies with RBC size and hgb content

Adds little information

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RBC Indices

Evaluation:
3 adults

Homogeneous Population

Heterogeneous Population

(1) Leukopenia, normocytic anemia, low platelets

(2) Leukocytosis, microcytic anemia, high platelets
(3) Macrocytic anemia
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Evaluation:

Evaluation:

Schistocytes

Spherocyte

Spherocyte

This blood smear shows:

1. Uniform RBC size
sizea homogeneous population of
red cells with a low RDW value
2. Wide variations in RBC size
sizea heterogeneous
population of red cells with a high RDW value

Wide variations in RBC size and a high RDW

17

CLS500 Application and Interpretation

of Clinical Laboratory Data
Hematology Tests Powerpoint Handout

The red cells shown are:

1. Deformable and normal in shape
2. Rigid/damaged and survival will be shortened

Rigid/damaged red cells that indicate RBC

destruction

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Platelet Count

Platelet Count
Hardest cell type to count

PLT count - total # of platelets reported in

thousands/uL
thousands/uL

All critical and/or flagged PLT counts are

verified microscopically (blood smear)

Reference range
150,000150,000-450,000/uL

A major source of error is platelet clumping

Caused by partially clotted EDTA blood or
heparinized blood

Significance
PLT count
count.Thrombocytopenia

Sample must be
redrawn to obtain
accurate results

Decreased production, increased use/destruction

PLT count
count.Thrombocytosis
Increased production, postpost-splenectomy

Blood smear

Platelet

Critical values: PLT <40,000 or >1 million/uL

million/uL

Platelet Clumps
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CBC & Automated Differential

Identify the cell shown

Normal reference range for age

and sex

CBC

DIFF
WBC
Types

A puppy
puppy paw

% x WBC/uL

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CBC & Manual Differential

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Differentials

Parameters with * are outside

reference range for age & sex

Automated or manual if significant patient

abnormalities exist
Manual differentials require a blood smear exam

Differential includes:
WBC differential that classifies WBC types
Reported in % and absolute # (% x WBC count)
% easier to evaluate but absolute # more reliable

Cell morphology (blood smear)

Significant variations from normal appearance of
red cells, white cells and platelets are noted or
quantitated on report

Blood
Smear

Significant variations
from normal are noted

CLS500 Application and Interpretation

of Clinical Laboratory Data
Hematology Tests Powerpoint Handout

Specific abnormalities can provide clues to the

cause of a condition/disorder
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Differentials

Reticulocyte Count

Reference percentage ranges vary with age

Measures rate of RBC production by the bone

marrow
Retics appear as polychromasia on a Wright
Wrights stained
blood smear
smearmust order a retic count for number

Automated or manual using supravital stain

Reported in % and absolute # (% x RBC count)
Absolute # is more reliable than %

Significance:

NRBC

Deviations from normal may indicate disease; the cell

type involved is often related to function
No immature cells should be present

Polychromasia

Critical values: Blasts, other highly abnormal

findings; absolute neutrophil # <500/uL
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Supravital stained smear

Erythrocyte Sedimentation Rate

Reticulocyte Count

The ESR or sed rate is a non-specific indicator

of disease
Normal
Abnormal

Reference range varies with age

Adult 0.50.5-2.0%
Newborn 2.02.0-6.0%

Wright
Wrights stained smear

Reticulocytes

2525-100,000/cmm Absolute#

Mainly used to monitor patients

with chronic inflammatory disease

Significance
absolute Retic count
count.Reticulocytopenia

Abn

ESR refers to the rate red cells

settle as blood stands in a tube

Decreased RBC production

absolute Retic count

count.Reticulocytosis
Increased RBC production ( EPO stimulus)
Good indicator for hemolytic anemias

In normal persons, sedimentation

or falling of red cells is slow
Automated or manual
Reported in distance the red cells
fall in mm/time.mm/hr
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Erythrocyte Sedimentation Rate

Erythrocyte Sedimentation Rate

Reference range varies with age & sex

Males 0-10 mm/hr
Females 0-20 mm/hr

Significance of increased/abnormal ESR results:

Males>50y 0-20 mm/hr

Females>50y 0-30 mm/hr

Significance

Rouleaux

Under normal conditions, red cells

do not form rouleaux.fall slowly

Acute and chronic infectionsbacterial

Chronic inflammatory disordersRA, SLE
Malignanciescancer, lymphoma, multiple myeloma
Tissue necrosismyocardial infarction
Anemia of chronic disease

Clinical use

High concentrations of certain plasma

proteins promote rouleaux = ESR

Monitor response to therapy for rheumatoid arthritis

Follow Hodgkins for relapse
Help detect occult disease (CRP more sensitive)

Fibrinogen, a positive acute phase reactant, is most

responsible for an increased/abnormal ESR
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CLS500 Application and Interpretation

of Clinical Laboratory Data
Hematology Tests Powerpoint Handout

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Example of hemodilution:
hemodilution:

Evaluation:

Line draw @ 04:45 from ICU patient

Redraw to confirm was requested

Next step:
1. Order a differential to identify WBC types and cause
for WBC count
2. Request a redraw to confirm the platelet count
3. Order a retic count to access RBC production
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Evaluation:

Order a diff to ID cause for high WBC count32

Evaluation: What do you suspect?

SOB, jaundice &
hemoglobinuria

Next step:
1. Order a differential to identify WBC types
2. Request a redraw to confirm the platelet count if no
signs of bleeding
3. Order a retic count to access RBC production

Request a redraw to confirm results

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Hemolytic anemia.find cause

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Evaluation: What do you suspect?

Fever

Bacterial
infection
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CLS500 Application and Interpretation

of Clinical Laboratory Data
Hematology Tests Powerpoint Handout

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