Dr. Sanwar Agrawal MD Ekta Institute of Child Health Raipur: Published by

ABC of CBC Is it so simple?
Dr. Sanwar Agrawal MD Ekta Institute of child health Raipur PUBLISHED BY www.medicalppt.blogspot.com
www.medicalppt.blogspot.com
Yes, it is!
The complete blood count (CBC) is a deceptively simple test to order and interpret
Provided, You concede that it is difficult to be simple.
The CBC is a bargain; its cost can be much less than modern imaging studies, but like the modern imaging studies, its value is lost without appropriate analysis.
Because of explosion of new technology and information, understanding of and sophisticated use of the CBC will take on added importance.
What is CBC?
Measured parameters: Hemoglobin, MCV, and erythrocyte count Hemoglobin concentration is measured by absorbance spectrophotometry and relies on complete lysis of erythrocytes. Platelets, WBC
Derived parameters: MCH, MCHC, and hematocrit
The hemoglobin, MCV and RBC count are the measured parameters
The technique
electric impedance
Flow cytometry
Impedance
Erythrocyte counting and size determination are accomplished by passage of cells through an electric field created by direct current As the cells pass singly through the field, a small resistance is generated that is measured as a pulse height. From the pulse height, the size and number of erythrocytes are determined. These data are frequently plotted as a histogram in the typical modern Coulter-type electric impedance instrument
Flow cytometry
With the Advia, red cells are sphered in a diluent and then passed through a laser. The cells scatter light (at different angles) which is detected by the instrument (see image to the right). The laser detects the number of cells, cell volume (using low angle scatter) and internal content, i.e. hemoglobin concentration (using high angle scatter) by light scatter.
The rule of 3
the measured hemoglobin concentration is approximately three times the RBC count, and the calculated hematocrit is three times the hemoglobin value. When significant deviation occurs from these approximate calculations, artifacts in the CBC should be suspected
ARTIFACTS IN ELECTRONIC CELL COUNTING

Cause Hb Hct RBC MCV MCH MCHC
Cold agglutinins
-- ------
---
Hyperleukocytosis
Hyperosmolar plasma-
Spun V/S Automated Hct.
Spun > Automated. Spherocytes, sickle erythrocytes, hypochromic cells, and reticulocytes, trap more plasma. To permit close correlation between the manual and automated hematocrits, a correction factor of approximately 3% is applied to the calculation of the hematocrit .
A case can be made to dispense with reporting a calculated hematocrit with the CBC because the hemoglobin value that is measured directly is more reliable
MCV
The mean cell volume indicates the volume of the "average" red cell in a sample. It is expressed in femtoliters (fl; 10 -15 liters). With impedance analyzers, the MCV is measured by averaging the amplitude of the pulses created as the cells pass the aperture of the counter.
MCV
The instrument using scattered light also plots the cell volume and hemoglobin concentration together in a volume/hemoglobin (V/HC) cytogram. Normal red blood cells with normal volume (normocytic) and hemoglobin concentration (normochromic) are found in the middle box
MCV
Agglutinated cells (arrow) with IHA form a distinct cluster (macrocytic normochromic) above the normal red cells (arrowhead) A. Normal RBC V/H cytogram B. Polychromasia: the polychromatophils form a discrete cluster (arrow) that extends off the normal red cell population (arrowhead) and is macrocytic and hypochromic.
Micro and Macrocytes
Neonate MCV > 100 fl. After 6 months age : 70+ age in years ( lower limit of normal) 84+0.6 x ( age in years)= upper limit of normal. Corresponding adult values are 80 and 96 respectively.
Mean Cell Hemoglobin
This represents the absolute amount of hemoglobin in the average red cell in a sample. The MCH is calculated from the [Hb] and the RBC using the following equation: MCH (pg) = (Hb x 10) RBC This value is generally not useful A low MCH could be due to smaller than normal cells with normal Hb concentration, or normal sized cells with lower than normal Hb concentration
Mean Cell Hemoglobin Concentration (MCHC)
MCHC is the mean cell hemoglobin concentration, expressed in g/dL It can be calculated from the [Hb] and the PCV using the formula: MCHC = (Hb PCV) x 100. The normal value for MCHC is about 33%. Values for MCHC significantly above the reference range are not physiologically possible due to limitations on the solubility of Hb.
For all practical purposes a MCHC > 35% and RDW >14 is Spherocytosis
Red Cell Distribution Width (RDW)
The RDW is an index of the variation in cell volume within the red cell population. RDW = (Standard deviation of red cell volume mean cell volume) x 100 Red cell populations with higher than normal RDW are termed heterogenous; those with normal RDW are homogeneous. Its a measure of anisocytosis
RDW..
In some instances, the RDW is the first test result to increase with changes in red cell population sizes. In early iron deficiency, there are only low numbers of microcytic red blood cells. This will increase the standard deviation and the RDW, but the mean cell volume is unchanged because there are insufficient numbers of microcytic cells to change the mean volume
MCV and RDW

MCV low RDW normal RDW high MCV normal MCV high Aplastic anemia Folate/B12 def IHA
Thalassemia Chronic trait disease Iron deficiency Early Iron/folate def Myelofibrosis
Microcytosis and raised TRBC
Only 3 conditions: B Thal Trait, Hypoxic erythrocytosis, Polycythemia vera. RDW is normal in first and increased in rest. For pediatric age group: Microcytosis, raised TRBC and normal RDW is B Thal trait.
Platelets
A low counts should be cross checked manually. Small RBCS (like in IDA) may be counted as platelets ( One explanation for increased Plt in IDA). Platelet clumps are responsible for low counts.
1. 2. 3. 4. 5. 6.
Platelets Large platelets Red blood cells RBC fragments Debris Ghosts
MPV
Large Platelets: Macrothrombocytes (MPV >10 fl) Idiopathic Thrombocytopenic Purpura Bernard-Soulier Disease May-Hegglin Anomaly Small Platelets: Microthrombocytes (MPV <6 fl) Aplastic Anemia Wiskott-Aldrich Syndrome Thrombocytopenia-absent radii (TAR Syndrome) Storage Pool Disease
WBC
Nucleated red blood cells are counted by all hematology analyzers (regardless of technique) as white blood cells. For this reason, the white blood cell count must be corrected for the number of nucleated red blood cells in the circulation. To correct a leukocyte count, the number of NRBCs per 100 leukocytes is recorded during the differential leukocyte count. Then a correction is made as follows: Corrected WBC = nucleated cell count x (100 [nRBC + 100])
A. Neutrophils B. Monocytes C. Lymphocytes D. Eosinophils E. Large unstained cells F. Platelets/noise G. Debris/noise
In this cytogram, the cells are displayed as a worm, with the mononuclear cells (lymphocytes and monocytes) in the head and the granulocytes (neutrophils) in the body of the worm.
CBC IS A LAUGHING GAME
THANKS! For more lectures visit www.medicalppt.blogspot.com


Dr. Sanwar Agrawal MD Ekta Institute of Child Health Raipur: Published by

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ABC of CBC Is it so simple?

Provided, You concede that it is difficult to be simple.

Derived parameters: MCH, MCHC, and hematocrit

ARTIFACTS IN ELECTRONIC CELL COUNTING

Spun V/S Automated Hct.

Micro and Macrocytes

Mean Cell Hemoglobin

Mean Cell Hemoglobin Concentration (MCHC)

Red Cell Distribution Width (RDW)

MCV and RDW

Microcytosis and raised TRBC

A. Neutrophils B. Monocytes C. Lymphocytes D. Eosinophils E. Large unstained cells F. Platelets/noise G. Debris/noise

CBC IS A LAUGHING GAME

THANKS! For more lectures visit www.medicalppt.blogspot.com

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