Unicel DxH 800 Flags, Codes, & Messages

Unicel DxH 800 Flags, Codes, & Messages
Rev. A (May 2012) UniCel DxH 800 Flags Codes and Messages INSTRUCTOR NOTES: The UniCel DxH 800 incorporates technological advancements within the analytical modules, advances in signal processing and innovative algorithm applications to create a cellular analysis system that redefines differential data collection and analysis, we in Beckman Coulter are raising the WBC differential to a new standard of efficiency. The DxH has flags, codes and messages to help you analyze the specimens. We are going to go over most of them, some of these FCM you will probably never see them, but we will go over them so you can learn and become familiar and allows you to ask questions. Please before we begin as always you need to follow your Regulatory Agencies and or your laboratory protocols. Our goals is to help you understand these FCM is your responsibility to adhere to yours laboratory protocols when reviewing manual differentials. Things you need for the PPT to pass around as examples: Flow Cell Aperture bath with apertures mounted Automated Power Easy Use Flexible Rev. A (May 2012) Professional Development © 2012 Beckman Coulter, Inc. Professional Development

Rev. A (May 2012) Objectives Flags Codes Messages CBC Parameters Cellular Interference Differential Parameters NRBC Parameters Retic Parameters The Objectives of this presentation are the following: Flags Codes Messages CBC Parameters Cellular Interference Differential Parameters NRBC Parameters Retic Parameters Rev. A (May 2012) Professional Development © 2012 Beckman Coulter, Inc. Professional Development

Rev. A (May 2012) Flags appear in one of four positions to the right of the result. The flags are listed in order of priority within each space. It is possible to have flags in each of the four positions. 1. E,e, +, -, and R: E, e: Edited parameter, result calculated from edited. + and - Above/below measuring range. If above make a dilution. If below, it is probably a body fluid. Follow your lab protocol. 2. a,c L and H: Action, & Critical Ranges based on Lab Protocol 3. H,L: Reference Ranges (Normal) based on Lab Protocol 4. P,N,D: Usually related to System Messages (P, N, D). The Blood detectors are active at all times. Same pathway for both the cassette presentation and single tube presentation. You will see this in both modes if partial aspiration is detected. P: (for Pedro) Partial aspiration detected. Partial Aspiration, System Message. Comes from the front and rear Blood detector. The Blood detectors on this instrument have been redesigned, new style which goes down to a lower hemoglobin (Hgb to 2). Also, with this instrument having the same aspiration pathway, the blood goes through the front and rear blood detectors. No more Mode-To-Mode comparison. N: Non-blood detected, but aspirated. Usually a fluid. P & N Flags are associated with System Messages. D: Delta check per your lab protocol. If the Delta is triggered it is also based on the Lab Protocol. Rev. A (May 2012) Professional Development © 2012 Beckman Coulter, Inc. Professional Development

Rev. A (May 2012) New codes #####, ===== ===== Disabling the Analysis (Menu>Setup>System>Analysis) Disable (Temporarily or Permanent) Diff, NRBC, Retic Note: The only thing you may permanently disable are Retics. If you wish to have them enabled at a later date, you must call Service. You may temporarily disable Diff, Retic, and NRBC. XXXX Deselecting a Test Parameter from the reporting. If you disable the WBC when you enable it again all previously analyzed samples will display the XXXX. You will probably never see this. Is very rare that you will disable a parameter. ::::::: Flow Cell Clog (System suspects a clog in the Flow Cell) ----- Total voteout (Aperture Bath): This is a triple aperture system. 2 of the 3 aperture reading have to agree. You may view the results of aperture 1, 2 & 3 from the Additional Tab in the Patient’s Results Screen specially when there is an aperture that is voting out. It may be a hardware problem (ie: clogged aperture or defective aperture). ……… Incomplete computation: The instrument does not have a piece of its formula to calculate a result. (ie: no value for WBC parameter result, then the Diff Absolutes will have an Incomplete Computation). If WBC then the diff abs# will have an…… +++++ Results exceed the operating range: No way to go in and see what the result is. You just have to make a dilution. ????? Results outside of the range of values that can be formatted for display (HGB results is lower than the blank) #####: Results were rejected. Sample was run, the algorithm did not know what to do with the recovered results, so it did not accept the results. Rev. A (May 2012) Professional Development © 2012 Beckman Coulter, Inc. Professional Development

Rev. A (May 2012) Messages Results related: Suspect: messages are generated by internal algorithms to convey that a clinical condition may exist with a specimen based on an abnormal cell population or distribution. System: messages indicate an event that may affect the operation of a system, requires operator notification and or entry into a History Log. Most accompanied by an R (review) flag Some are accompanied by N or P flags Definitive: defined by the Operator Suspect: Generated by the internal Algorithms. It’s telling me that there is a clinical condition happening in this tube of blood to the cells. The instrument is suspecting based upon clinical patterns that the sample has for example sickled cells, immature granulocytes, an abnormal condition of the blood. Usually a condition that you want to know about so that you can further investigate that sample. It’s related to an abnormal cell population or distribution. System: These messages are relative to an event that occurred during the cycle (CBC, CD, CDR), it indicates an event occurred that may affect the operation of the system and therefore may have affected my sample results. The majority of the system messages are accompanied by an R flag and some of them are accompanied by an N or P flag. To rephrase that, all the system messages are accompanied by an R flag except for the aspiration which are accompanied by an N or P. Definitive: Lab defines these. (ie: Critical, Normal Ranges, Action Ranges). Rev. A (May 2012) Professional Development © 2012 Beckman Coulter, Inc. Professional Development

Rev. A (May 2012) Exception or System Status Messages Exception: anything with an exception won’t be released, for example – default test order System Status: an event that may affect system operation. Accompanied by operator notification and entry into log. Chapter 6 > Data Review > Processing Results Exception: If you get an exception message, it means that the results won’t be released. (ie: a default test was run). Scenario: you run a sample that has not been received in your Lab LIS system therefore your LIS did not transmit the information to your pending list, it has a barcode and that’s fine. The specimen has a barcode number but it doesn’t find that order on your pending list. What the system does is run that sample with whatever default test order you have. That will automatically hold those results as an exception. Then you have to review the results at the instrument and release them to the LIS and the LIS grab whatever results it need. System Status: You will get a message and the history log icon will be in red. The operator would need to review this message. Rev. A (May 2012) Professional Development © 2012 Beckman Coulter, Inc. Professional Development

Examples Rev. A (May 2012) Explain where they will see the Flags related to the parameter results Suspect/System/Definitive Messages - explain where they are Explain location of Exceptions Explain Additional Data navigation icon Rev. A (May 2012) Professional Development © 2012 Beckman Coulter, Inc. Professional Development

Rev. A (May 2012) Data Fusion Use the mouse in the computer to activate the video In the following sections we will be talking about CBC, Diff, Retic, NRBC. Before we continue with the FCM, I would like to explain to you the technologies that are currently utilized in the DxH 800. This will help you understand the flagging process. Data Fusion: One of the most exciting technologies to me on the DxH is Data Fusion. The DxH is able to combine data from multiple sources and gather that information together. More accurate information about a parameter than if they were achieved by means of a single source. It uses the diff information which is shared with the CBC (whites, reds, platelets) and that information is shared with the Retic information and the nRBC information. They are talking to each other. This is known as Datafussion. This determines what needs to be flagged, coded, or messaged. The Datafussion is a big part of the DxH technology. The patented algorithms developed exclusively for the DxH allows for the most accurate and innovative analysis of cell population data possible. Watershed Concept: Watershed, defined as the valleys between elevations that catch rain, is conceptually similar to dataplot population peaks and valleys. The watershed concept digitally floods the dataplot, accenting obvious populations and exposing lesser populations unrecognized by other techniques. By exposing smaller subpopulations, the algorithm determines where the subpopulations belongs and how to apply appropriate algorithm gating. Templating Matching: The DxH 800 contains hundreds of templates patterns and if necessary it matches the pattern to a template from the library. Template matching is designed to digitally visualized and compare data patterns to provide optimal classification and flagging for each sample. Template matching compares an image of the sample data pattern to multiple template images of typical normal and abnormal data patterns. Shape Signature: While Template Matching provides overall matching information, the shape signature digitally describes the three-dimensional shape of each differential population. This is used to determine population area and orientation. Rev. A (May 2012) Professional Development © 2012 Beckman Coulter, Inc. Professional Development

Cellular Interference
Unicel DxH 800 Flags, Codes, & Messages Cellular Interference Rev. A (May 2012) Suspect message Cellular Inter WBC & associated parameters, or TNC, flagged with R For CBC or CBC/Retic panels only, when NRBC are detected but not reported. System message Cellular Inter WBC & associated parameters, or TNC, flagged with R The results are only flagged if we are uncertain of the correction, or can’t correct (not just because a correction occurred). System Message “Cellular Interference”: Poor separation between a WBC population and interference. WBC correction was performed as a best estimation, and the WBC was flagged with an R. Cellular Interference comes from the 35 fL check in the WBC bath. In the WBC bath anything that is greater than 35 fL is a WBC, so we do a threshold check at 35 fL. ALL system messages are accompanied by “R” (Review) flag. Exceptions are the System messages associated with an Aspiration Error (P flag) and the Non-Blood Specimens message (N Flag). A system message indicated an event occurrence that may affect the operation of the system, requires operator notification, or entry into a History Log. Additional Notes: System: (Internal) An event occurrence that may affect the operation of the system. Something happened in the system that can not process, or during processing. Examples: R, P & N Flag. There was an occurrence during the CBC cycle that may have affected the results. Cellular Interference comes from the 35 fL check in the WBC bath. In the WBC bath anything that is greater then 35 fL is a WBC, so we do a threshold check at 35 fL. The WBC & associated parameters, or TNC (Total Nucleated Cells) will be flagged with an R. The results are only flagged if we are uncertain of the correction, or cannot correct (not just because a correction occurred). On the LH’s, UWBC= R, WBC = R (because of poor separation). Templating is like a fingerprint from the FBI going through the CSI (crime scene investigation) computer looking for a match. The system has hundreds of templates in the software. It doesn’t need to use it every time a sample is run. It only uses it as a help line, call a friend. So if the results have a pattern, then it will look for a template and match it. If the match is an exact may give you that abnormal flag, but may not flag the result with an R because it is confident. There are 3 levels of confidence, a matching score. (Low, Moderate and High). The Algorithm on this instrument is way more sophisticated. It’s important to distinguish that specially if you are keeping an LH. Suspect Cellular Interference: C or CR panel is ordered. The DxH still performs the NRBC analysis. If the system detects nRBC’s, it will generate a Cellular Interference Suspect Message to alert of their potential presence but will not report. The NRBC is still done in the background and uses Data Fusion to flag even a CBC panel. We want the nRBC technology to be done in the background this it’s going to help with the PLT flagging as we will see in a few minutes. If you get the Suspect Message Cellular Interference, What you can do: Write a Decision Rule: If Suspect Message Cellular Interference, Reflex to run a CD. On The DxH 800 instrument will report nRBCs starting from 0.1 and 0.2, not like the LH. It’s a different technology. LH’s reported at 2% or greater as per CLSI recommendation. You also have to decide if you want the nRBC going to the patient’s chartable records thru your LIS. Use the Classroom Examples Rev. A (May 2012) Professional Development © 2012 Beckman Coulter, Inc. Professional Development

Red Cell Messages Rev. A (May 2012) Suspect message Red Cell Agglut Data pattern consistent with the presence of agglutinated red cells Suspect message Dimorphic Reds Data pattern consistent with the presence of multiple red cell populations Dimorphic Reds: You can see the 2 populations on the RBC histogram. We begin counting RBCs at 36 fL. This is typically seen after transfusions. Red Cell Agglutination: Looking at the foot or the toe of the RBC histogram. The higher the foot of the RBC histogram, could indicate agglutinated RBC’s, causing a higher value of MCHC. Histogram may be right shifted. Labs may warm the specimen to rule out cold agglutinin or Rouleaux. Additional Notes: HEM.30150 Is a documented procedure in use to detect other spurious CBC instrument results that may be clinically significant (e.g., pseudomacrocytosis from rouleaux or agglutinates; pseudoleukocytosis with erroneous hemoglobin, falsely low erythrocyte count and hematocrit; hyperlipemias)? We have the pseudomacrocytosis from rouleaux or agglutinates covered with these Decision Rules: Name: MCV Rule If MCV < 60.0 or > – PERFORM RBC MORPHOLOGY REVIEW And Name: MCHC > 36.5 If MCHC > 36.5 – REPEAT. CHECK FOR LIPEMIA, ICTERUS, COLD AGG & FOLLOW SALINE REPLACEMENT PROCEDURE. Rev. A (May 2012) Professional Development © 2012 Beckman Coulter, Inc. Professional Development

RBC Fragments/Microcytes
Unicel DxH 800 Flags, Codes, & Messages RBC Fragments/Microcytes Rev. A (May 2012) Suspect message RBC Frag/Micro Pattern observed consistent with the presence of RBC fragments and/or microcytic red cells. Again RBC’s start at the 36 fL baseline. In this example the curve does not start at the baseline. The Histogram is shifted to the left. Additional Notes: (This flag is generated by mathematical techniques in the algorithm) HEM.30150 Is a documented procedure in use to detect other spurious CBC instrument results that may be clinically significant (e.g., pseudomacrocytosis from rouleaux or agglutinates; pseudoleukocytosis with erroneous hemoglobin, falsely low erythrocyte count and hematocrit; hyperlipemias)? We have the pseudomacrocytosis from rouleaux or agglutinates covered with these Decision Rules: Name: MCV Rule If MCV < 60.0 or > – PERFORM RBC MORPHOLOGY REVIEW And Name: MCHC > 36.5 If MCHC > 36.5 – REPEAT. CHECK FOR LIPEMIA, ICTERUS, COLD AGG & FOLLOW SALINE REPLACEMENT PROCEDURE. Suspect Flags: RBC Frag/Microcytes The specimen may contain red cell fragments and/or some microcytic red cells We have the “falsely low erythrocyte count and hematocrit” covered with this Decision Rule: Name: RBC Frag / Micro If (Suspect messages Equal To RBC Frag / Micro) Comment: PERFORM RBC MORPHOLOGY REVIEW And it is also covered with the Decision Rule: Name: ASPIRATION PROBLEM If (System messages Equal To Unknown Error) Or (System messages Equal To No Aspiration) Or (System messages Equal To Non-Blood Specimen) Or System messages Equal To Bubbles) or (System messages Equal To Carryover) Comment: CHECK SAMPLE FOR CLOTS & FOLLOW LAB PROTOCOL The pseudoleukocytosis with erroneous hemoglobin is covered with the Decision Rule for System Messages where the Hgb may be flagged with an R. Rev. A (May 2012) Professional Development © 2012 Beckman Coulter, Inc. Professional Development

Giant Platelets Rev. A (May 2012) Suspect message Giant Platelet May be accompanied by System message specific to platelet results Giant Platelet data pattern observed This message may also be accompanied by a System message specific to platelets results. Platelets are now generally collected between 2 and 25 fL and they are now channelized to 256 channels for better resolution. This resolution in addition to the Datafusion with the NRBC and CBC module improves Giant Platelet flagging. Take a look at the tail of the histogram how it stops and drops off sharply. Notes: On the platelet histogram the tail of the histogram stops and drops off sharply. Look at the NRBC1 dataplot. This is a distinct giant platelet pattern. 2-20 fL for the LH and 2-25 fL for the DxH 800 Rev. A (May 2012) Professional Development © 2012 Beckman Coulter, Inc. Professional Development

Platelet Clumps Rev. A (May 2012) System message Platelet Clumps PLT & associated parameters flagged with R Clumped platelet data pattern observed On the platelet histogram. The tail of the histogram tapers off and the pattern on the NRBC is distinct for platelet clumps. Again, the use of data fusion to improve flagging rates. Notes: Platelet clumps may appear anywhere throughout a WBC histogram depending on the size of the clump. Rev. A (May 2012) Professional Development © 2012 Beckman Coulter, Inc. Professional Development

Platelet Messages Rev. A (May 2012) System message RBC-PLT Overlap PLT & associated parameters flagged with R PLT histogram shows a possible interference with larger platelets System message PLT Inter: Debris PLT & associated parameters flagged with R PLT requires review due to the possible presence of an interference with small platelets PLT Inter: Debris Platelet Interference from debris: You could see it in patients with a high build up of toxins in the body for example: Pre-Dialysis Can’t tell where the platelets end and the red cells (or red cell debris) starts. Possible causes: Large Platelets, RBC fragments, clumped Platelets. Review of other histograms may give a hint. RBC-PLT Overlap RBC-PLT Overlap: Platelets are counted up to 25 fL and RBC’s are not counted until 36 fL. RBC fragments and microcytes could be located on the unknown region. The region from where the platelet stopped being counted and when the RBC started counting. The instrument is telling you that there may be something there. It’s an overlap. The platelets did not come down to baseline. Is it giant platelets or is it RBC microcytes? Notes: Low end interference that may affect the accuracy of the platelet count is observed at the far left. If the established limits are exceeded the instrument will generate a flag. LH has a log normal fitted curve. The DxH 800 does not. Rev. A (May 2012) Professional Development © 2012 Beckman Coulter, Inc. Professional Development

WBC Interference from HGB
Unicel DxH 800 Flags, Codes, & Messages WBC Interference from HGB Rev. A (May 2012) System message WBC Inter: HGB HGB & associated parameters flagged with R HGB may not be adequately corrected for WBC interference There is a formula based on historical data that is applied to the HGB beginning at a WBC of If the instrument is unable to adequately correct then the system message will be generated. NOTE: Possible causes: High cryoglobulins and/or plasma proteins and/or giant platelets as observed in Waldenstron’s Macroglobulinemia. All of the parameters will be corrected at 140,000 WBC count. There is no correction for lipemic specimens. Rev. A (May 2012) Professional Development © 2012 Beckman Coulter, Inc. Professional Development

Differential Parameters
Unicel DxH 800 Flags, Codes, & Messages Rev. A (May 2012) Differential Parameters Now, let’s look at the Differential Parameters Rev. A (May 2012) Professional Development © 2012 Beckman Coulter, Inc. Professional Development

Rev. A (May 2012) One Cell at a Time . . . WBCs are hydrodynamically focused The cells pass through the flow cell sensing area “one cell at a time”. This is what we call hydrodynamically focused. This is done with the assistance of the sheath fluid. Rev. A (May 2012) Professional Development © 2012 Beckman Coulter, Inc. Professional Development

Flow Cytometric Digital Morphology
Unicel DxH 800 Flags, Codes, & Messages Flow Cytometric Digital Morphology Rev. A (May 2012) Multiple angles of light scatter, captures 10X more data than previously possible AL2 (axial light loss) LALS (lower angle LS) LMALS (lower med angle LS) UMALS (upper med angle LS) MALS (median angle LS) Innovative Data Analysis Techniques Improvements in differential accuracy and flagging efficiencies are obtained by combining the additional light scatter measurements with innovative data analysis techniques to better define and separate cell populations. We not only have Volume, Conductivity and Scatter. We’ve taken Scatter to a new dimension. We have multiple angles of Light Scatter, which distinct parameter measurements for each cellular event. - Axial light loss (AL2) - Low angle light scatter (LALS) - Median angle light scatter (MALS) - Lower median angle light scatter (LMALS) - Upper median angle light scatter (UMALS) Rev. A (May 2012) Professional Development © 2012 Beckman Coulter, Inc. Professional Development

Rev. A (May 2012) Flow Cytometric Digital Morphology Double Click on Video to Play With this new data acquisition technologies, including high definition digital signal processing and multiple angles of light scatter, gather significantly more data on each cell then any previous product or technology within Hematology. For example: Each cell analyzed for the WBC differential yields 29 individual pieces of information for almost 10 times more data than previously possible. This dramatic increase in high definition data acquisition and technologies enables laboratories to have far greater cellular resolution leading to improved sensitivity and specificity of cellular classification. This shows the specific angles, or location of the light scatter. Data Transformations stretch and separate populations mathematically enhancing the differential populations. This process enhances population differences and exposes any cellular subpopulations. Watershed Concept is a unique technique that searches for populations of cells. The watershed concept digitally floods the dataplot, accenting and exposing populations unrecognized by other techniques. By exposing smaller subpopulations, the algorithm determines where the subpopulation belongs and how to apply appropriate algorithm gating. Shape Signature The UniCel DxH 800 flagging algorithms use flagging criteria from many independent sources, such as Template Matching, Shape Signature, Population Statistics, CBC data, and NRBC data. This process ensures that the algorithm accounts for the complex nature of the patient sample and minimizes inherent bias that may be introduced when using only one technology Surface Plots 2D Data Plots = Core dataplots, developed from the combination of measurements and transformations that best enhance and separate cell populations, are available for visual review in both two-dimensional dataplot format and surface plot format. Rev. A (May 2012) Professional Development © 2012 Beckman Coulter, Inc. Professional Development

Differential Parameters
Unicel DxH 800 Flags, Codes, & Messages Rev. A (May 2012) Differential Parameters MONO EOS NEUTS Class participation. Ask the class what is each Population Spatial position. Use the mouse and click for the population names to appear Neuts Lymphs Monos Eos Baso A typical WBC Diff analysis evaluates 8,192 cellular events for approximately 250,000 pieces of cellular information on cell size, shape and morphology!! LYMPH BASO Rev. A (May 2012) Professional Development © 2012 Beckman Coulter, Inc. Professional Development

Abnormal Cell Distribution
Unicel DxH 800 Flags, Codes, & Messages Rev. A (May 2012) Abnormal Cell Distribution 1 2 3 4 5 6 7 8 1 MO Blasts 2 NE Blasts 3 Immature Granulocytes 4 Band Neutrophils 5 LY Blasts 6 Variant Lymphocytes 7 Small Lymps / Low Opacity 8 Non-White Cells MO Blasts NE Blasts Immature Granulocytes Band Neutrophils LY Blasts Variant Lymphocytes Small Lymps / Low Opacity Non-White Cells Rev. A (May 2012) Professional Development © 2012 Beckman Coulter, Inc. Professional Development

LY Blast Rev. A (May 2012) 5PD1 5PD2 Normal 5PD1 Suspect message LY Blast Blasts suspected in the LY area of the dataplot Data pattern consistent with possible presence of very immature cells The Blast sensitivity is not adjustable (default setting is set to highest sensitivity). Rev. A (May 2012) Professional Development © 2012 Beckman Coulter, Inc. Professional Development

MO Blast Rev. A (May 2012) 5PD1 5PD2 Normal 5PD1 Suspect message MO Blast Blasts suspected in the MO area of the dataplot Data pattern consistent with possible presence of very immature cells The Blast sensitivity is not adjustable (default set to highest sensitivity). Rev. A (May 2012) Professional Development © 2012 Beckman Coulter, Inc. Professional Development

NE Blast Rev. A (May 2012) 5PD1 5PD2 Normal 5PD1 Suspect message NE Blast Blasts suspected in the NE area of the dataplot Data pattern consistent with possible presence of very immature cells The Blast sensitivity is not adjustable (default set to highest sensitivity). Rev. A (May 2012) Professional Development © 2012 Beckman Coulter, Inc. Professional Development

Immature Granulocytes
Unicel DxH 800 Flags, Codes, & Messages Immature Granulocytes Rev. A (May 2012) 5PD1 5PD2 Normal 5PD1 Suspect message Imm Grans [Metamyelocytes, myelocytes &/or promyelocytes] or [myelocytes & promyelocytes] Variable sensitivity with default set at high Beckman Coulter suggests leaving the sensitivity set to high to avoid false negatives (FN). Before adjusting any variable sensitivities, the laboratory should always perform a flagging sensitivity study (Truth Table). CLSI recommends 40 samples most labs will perform 100 samples. This is not just a slight left shift. This is a pretty sick patient potentially with metas, myelos, and promyelos. Compares to the LH Imm NE2 flag. Rev. A (May 2012) Professional Development © 2012 Beckman Coulter, Inc. Professional Development

Left Shift Rev. A (May 2012) 5PD1 5PD2 Normal 5PD1 Suspect message Left Shift Metamyelocytes, without more immature granulocytes Variable sensitivity with default at high Can be disabled Before adjusting variable sensitivities or turning off the left shift, the laboratory should always perform a flagging sensitivity study (Truth Table). If they are interested in the presence of bands, this flag should be left on. In regions where they are not interested in the band population, this band may be turned off and they will get what they need from the Imm Grans. Additional Notes: Imm Ne 1 Band 1 Rev. A (May 2012) Professional Development © 2012 Beckman Coulter, Inc. Professional Development

Variant LY Rev. A (May 2012) 5PD1 5PD2 Normal 5PD1 Suspect message Variant LY Variant (viral), atypical or abnormal LY suspected Variable sensitivity with default at high Note: Currently we don’t distinguish between a reactive (e.g. viral), immature, abnormal or malignant lymphocyte. Rev. A (May 2012) Professional Development © 2012 Beckman Coulter, Inc. Professional Development

Abnormal Diff Pattern Rev. A (May 2012) 5PD1 5PD2 Normal 5PD1 System message Abn Diff Pattern Results do not match any known template All Diff results accompanied by R flag The DxH only uses template matching when necessary. If no template match is found, this message will be generated. The DxH 800 contains hundreds of templates patterns and if necessary it matches the pattern to a template from the library. Rev. A (May 2012) Professional Development © 2012 Beckman Coulter, Inc. Professional Development

NRBC Rev. A (May 2012) 5PD1 5PD2 Normal 5PD1 Suspect message NRBC NRBC suspected in the signature position of the dataplot Only in condition where the NRBC module is disabled and the panel includes a Diff Menu/Setup/System Setup/Analysis and disable temporarily. You can disable: Diffs, Retics, NRBC. Rev. A (May 2012) Professional Development © 2012 Beckman Coulter, Inc. Professional Development

Aged Sample Rev. A (May 2012) 5PD1 5PD2 Normal 5PD1 System message Aged Sample All Diff results accompanied by R flag The results are only flagged if we are unable to give a correct differential, not just because aging is present. It is not just generated because it is an aged sample. If the instrument can obtain a pattern or a template it will not give you the system message. Rev. A (May 2012) Professional Development © 2012 Beckman Coulter, Inc. Professional Development

Excessive Debris Rev. A (May 2012) 5PD1 5PD2 System message Excessive Debris: D All Diff results accompanied by R flag The # of debris events is too high compared to white events during diff analysis. May be seen in pre-dialysis and chemo specimens. Note: D=Diff, R=Retics, N=NRBC Note: For troubleshooting purposes is this scenario happening with one sample versus multiple samples, it could be the instrument. Rev. A (May 2012) Professional Development © 2012 Beckman Coulter, Inc. Professional Development

NE-EO Overlap Rev. A (May 2012) 5PD1 5PD2 System message NE-EO Overlap All Diff results flagged with R Population shift observed (NE and EO not in correct spatial location) Watch for this flag with patients on bioresponse modifiers (Neupogen) (e.g. G-CSF, GM-CSF, interferons). Rev. A (May 2012) Professional Development © 2012 Beckman Coulter, Inc. Professional Development

MO-NE Overlap Rev. A (May 2012) 5PD1 5PD2 System message MO-NE Overlap All Diff results flagged with R Population shift observed (MO and NE not in correct spatial location) Watch for this flag with patients on bioresponse modifiers (Neupogen) (e.g. G-CSF, GM-CSF, interferons). Rev. A (May 2012) Professional Development © 2012 Beckman Coulter, Inc. Professional Development

Low Events: D Rev. A (May 2012) 5PD1 5PD2 System message Low Events: D Not enough events available for differential Low data acquisition during diff analysis. Low Acquisition event. Review according to your protocols Not enough cells. If this is happening with every sample it could be one of the following: Flow cell clog. What can you do??? Purge flow Cell What else can give you this message: Partial Aspiration Dirty AMTC Rev. A (May 2012) Professional Development © 2012 Beckman Coulter, Inc. Professional Development

High Opacity Events Rev. A (May 2012) 5PD1 5PD2 System message High OP Events All Diff results accompanied by R flag Interference in Opacity that has been observed with bone marrow samples or specimens with platelet clumps. This is a specimen with platelet clumps. Fibrin Strings Cryoglobulins Bone Marrow Sample Point out the area in the 5PD 2 dataplot (the red sickled formation). Rev. A (May 2012) Professional Development © 2012 Beckman Coulter, Inc. Professional Development

Low RMALS Events Rev. A (May 2012) 5PD1 5PD2 System message Low RMALS Events All Diff results flagged with R RMALS mode value is too low RMALS = Rotated Median Angle Light Scatter In this situation you may re-run the sample. It could be a bubble that went thru the flow cell. Rev. A (May 2012) Professional Development © 2012 Beckman Coulter, Inc. Professional Development

Rev. A (May 2012) NRBC Parameters PLT/DEBRIS WBC A typical NRBC analysis evaluates 8,192 cellular events for approximately 250,000 pieces of cellular Information on cell size, shape and morphology!! Use the mouse and click for the population names to appear…. NRBC WBC PLT/Debris NRBC Rev. A (May 2012) Professional Development © 2012 Beckman Coulter, Inc. Professional Development

Rev. A (May 2012) Abnormal NRBC Pattern NRBC1 NRBC2 System message Abn NRBC Pattern NRBC & associated parameters flagged with R Fits no known pattern Templating plays an important role. Normal nRBC Rev. A (May 2012) Professional Development © 2012 Beckman Coulter, Inc. Professional Development

Rev. A (May 2012) NRBC-LY Overlap NRBC1 NRBC2 System message NRBC-LY Overlap NRBC & associated parameters flagged with R Couldn’t separate NRBC from small LY during analysis May be a Baby sample (New Born). The Lymph's may be to small. Normal nRBC Rev. A (May 2012) Professional Development © 2012 Beckman Coulter, Inc. Professional Development

Rev. A (May 2012) NRBC Interference NRBC1 NRBC2 System message NRBC Inter NRBC & associated parameters flagged with R Significant amount of interference in NRBC regions that are not NRBC Potential lack of separation between nRBC’s and lymphs. Normal nRBC Rev. A (May 2012) Professional Development © 2012 Beckman Coulter, Inc. Professional Development

Miscellaneous NRBC Messages
Unicel DxH 800 Flags, Codes, & Messages Miscellaneous NRBC Messages Rev. A (May 2012) Detected by Hardware, not algorithm Flow Cell Clog: N System Event: N You can see it with Diff=D, Retic=R and N: NRBC. Rev. A (May 2012) Professional Development © 2012 Beckman Coulter, Inc. Professional Development

Reticulocyte Parameters
Unicel DxH 800 Flags, Codes, & Messages Rev. A (May 2012) Reticulocyte Parameters WBC’S MATURE RBC’S A typical RETIC analysis evaluates 32,000 cellular events for approximately 1 million pieces of cellular information on cell size, shape and morphology!! Use the mouse and click for the population names to appear Retics Mature RBCs WBCs PLT/Debris RETICS PLT/DEBRIS Rev. A (May 2012) Professional Development © 2012 Beckman Coulter, Inc. Professional Development

Abnormal Hemoglobin Rev. A (May 2012) Suspect message Abn Hemoglobin ‘Others’ category = green (~ platelets) & orange (not cleared) particles. Indicates a possible clearing problem in the presence of abnormal hemoglobin They are orange in color. Platelets are also labeled as "Others" but are a green color. (Related to the LH 700 series RUO Suspect message ‘Thalassemia’) May be do to: Hemoglobin S Hemoglobin C Clearing Solution because of a hemoglobin disease: Thalassemia We display unghosted (as in, not cleared) particles. We label them as "Others". Others is seen in the button “ View All VCSn Graphics” under dataplots. Normal Retic Rev. A (May 2012) Professional Development © 2012 Beckman Coulter, Inc. Professional Development

Rev. A (May 2012) Sickled Cells Suspect message Sickled Cells Data pattern consistent with sickled cells (Related to the LH 700 series RUO Suspect message ‘Sickle’) This flag does not mean the patient has sickle cell disease. You need to review according to your lab protocols. Normal Retic Rev. A (May 2012) Professional Development © 2012 Beckman Coulter, Inc. Professional Development

Retic System Messages Rev. A (May 2012) System message RET-RBC Overlap RET & associated parameters flagged with R. Unclear separation of retics & mature red cells. System message RET Inter: PLT RET & associated parameters flagged with R. The platelet population may have interfered with the RET. Try re-running the sample. Rev. A (May 2012) Professional Development © 2012 Beckman Coulter, Inc. Professional Development

Nucleated Cells Rev. A (May 2012) System message Nucleated Cells RET & associated parameters flagged with R NRBC or small WBC (especially small LY as in CLL) are visible in the dataplot (blue) and may have interfered with RET measurement Related to the LH 700 series RUO Suspect ‘Low Vol WBC’. Only appears if the whites can’t be separated from the retics. Rev. A (May 2012) Professional Development © 2012 Beckman Coulter, Inc. Professional Development

Flow Cell Clog Rev. A (May 2012) System message Flow Cell Clog: R RET and associated parameters flagged with R Hardware detected a flow cell clog during analysis It is possible to have a flow cell clog that is severe enough to inhibit data [:::::]. Rev. A (May 2012) Professional Development © 2012 Beckman Coulter, Inc. Professional Development

System Event During Retic
Unicel DxH 800 Flags, Codes, & Messages System Event During Retic Rev. A (May 2012) System message System Event: R RET & associated parameters flagged with R Hardware parameters were out of limit for an item that could affect RET analysis (e.g. voltage, temperature, pressure). Examples include (but are not limited to): Laser Offset Voltage failure Temperature Out of Range Maybe seen if the Temperature in the Retic Module is out of range. The Retic stain is kept at 41 degrees C. Rev. A (May 2012) Professional Development © 2012 Beckman Coulter, Inc. Professional Development

Rev. A (May 2012) Now that we have reviewed the different System and Suspect Messages. What can we do to address them? One thing that you could do is create Decision Rules to help you when analyzing the samples. One Decision rule can take care of all of the System messages. In most instances by re-running the sample the “R” flags can be eliminated. Decision Rule: If “R” flag on WBC or RBC or HGB or DIFF then Repeat CBC/DIFF. You can also create a separate rule for PLT R flag samples. Your Application Specialist will help you set up the Decision Rules and if applicable you can utilize the Consensus Rules. Consensus Rules: 41 rules created and installed in your instruments ready to be use. These rules are the recommendations from CLSI guidelines. Rev. A (May 2012) Professional Development © 2012 Beckman Coulter, Inc. Professional Development

Unicel DxH 800 Flags, Codes, & Messages

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Unicel DxH 800 Flags, Codes, & Messages

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