HEMATOLOGY WHAT IT IS : Study & measurement of individual elements of Blood. WHAT IT’S COMPOSED OF. SHOW SLIDES FROM PERIPHERAL BLOOD TUTOR CD OR USE PLATE FROM HEME II BOOK OR LOOK UP PLATE FROM FAVORITES-WEBPATH TODAY WILL COVER BASIC COCEPTS AND BLOOD MAKE-UP, NAME THOSE ELEMENTS OF BLOOD BUT CONCENTRATE ON THE RBC’S AND THE TESTS CONCERNING RBC’S Jane Finley, BS MT (ASCP) Nov 1, 2004 1

HEMATOLOGY AND LAB LANGUAGE Blood Serum Plasma Erythrocytes (RBC) Granulocytes (WBC) Platelets (Plt) As with any new learning experience it’s best to understand that most of the battle of learning is understanding the language used. Hematology has a very definite language must be recognized by anyone who orders tests and who needs to interpret findings in light of signs and symptoms already obtained. I’m going to introduce the terms that are used as we go through the areas of hematology we’ll be studying. We’ll begin with the most basic and move up to the most detailed. What is blood? What’s it’s main purpose?

55% Fluid; 44% Red blood cells; 1 % white blood cells and Platelets

Dissolved in the fluid part of blood, serum or plasma, are a variety of elements: analytes involved in metabolism, Na, K+, Cl--, Glucose, Nitrogen, Factors involved in clotting, fibringen, thromboplastin, clotting factors (F VIII) Factors involved in immune system: antibodies,

Lab Language: Hematology Testing Complete Blood Count (CBC) Erythrocyte Sedimentation Rate (ESR) Sickle Cell Screening Hemoglobin Electrophoresis Ferritin Iron Total Iron Binding Capacity (TIBC) Transferrin Most basic of tests done in lab for heme

Lab Language : CBC Hemoglobin Hematocrit RBC WBC Plt ct RDW MCV MCH MCHC Segmented Neutrophil Lymphocyte Monocyte Eosinophil Basophil Reticulocyte Reticulcyte Production Index (RPI) Individual parts of CBC; cells listed are counted individually and reported as % of whole WBC

Complete Blood Count White Blood Count (WBC) Red Blood Cell Count (RBC) Platelet Count (Plt) Hemoglobin (Hb or Hgb) Hematocrit (Hct) Red Cell Indices (MCV,MCHC,MCH) Red Cell Distribution Width (RDW) Differential Count (Diff) Most common test done; basic to health of individual; consists of very specific counts of formed elements of the blood. EVALUATION OF SIZE AND SHAPE of RBC Can be done without the differential but must indicate that you want a CBC no diff; most instruments give a diff automatically

CBC Differential -WBC Segs Lymphs/Atypical Mono’s Eo’s Baso’s Bands Metamyelocyte Myelocyte Promyelocyte Blast Enumerating individual blood cells; commenting on abnormal structures that may be clinically significant

CBC Differential-RBC Anisocytosis Microcytes Macrocytes Nucleated RBC Howell Jolly Bodies Basophilic Stippling Hypochromia Riticulocytes Poikilocytosis Teardrop Ovalocytes Helmet cells Sickle Cells Don’t actually count; compare RBC against normal and report degrees of abnomality seen( 1+,2+,3+….) Abnormality of RBC caused by conditions from various disorders; Microcytosis from malnutrition, FE def anemia; Sickle cell from abnormal hemoglobin S; Ovalocytes from abnormal Heme structure.

Cell Counts: Number of cells per liter of whole blood Terms Leukocytosis Erythrocytosis Erythropenia Thrombocytosis Thrombopenia WBC 4.5-11.0 x 109/L RBC Males: 4.3-5.7 x1012/L Females: 3.8-5.1 “ Plt 150-400 x109/L Leukocytosis: Increase in WBC count Erythrocytosis: Increased RBC =>6.0 ; Erythropenia: <3.8 Thrombocytosis: increase in platelets; Thrombopenia: decrease in plt We will move on the the RBC portion of our learning unit and do WBC next week.

Hemoglobin Heme + protein (globulin) Main purpose is to carry O2 Three main types Variants result in identifiable disorders Normal ranges are age and gender related Prinicipal adult Hbg: A1, A2; normally make-up 95%, Hgb F 5%: Genetic varients interfer with O2 carrying capability: S,C, D, E inherited abnormality. Oxyhemoglobin: Heme + O2 from lungs to tissue. O2 exchanged at tissues for CO2 Carboxyhemoglobin: Hemoglobin has greater affinity for CO than O2. (200X’s). Can’t carry O2 if combined with CO causing carbon monoxide poisoning. Skin will turn bright cherry red, high levels causes axphyxiation. Reversible condition; Smokers blood can show as high as 10% of hemoglobin. Small amount normal, <1% Caroxyhemogl Hemoglobin disorders: Sickle Cell(S,C), Thalassemias(A2)

Hematocrit Packed Cell Volume Measures what percentage of whole blood is represented by RBC Compares RBC and hemoglobin Normal ranges are age and gender related Small amount of blood collected in a capillary tube, spun down for specified amount of time, measured to ascertain what % of the whole is RBC. Results are effected by size of RBC,amount of Hgb in cell, hydration of patient, condition of samples(hemolysis), technique of collection and procedure.

Lab Language: Red Cell Indices MCV- Mean Corpuscular Volume MCH-Mean Corpuscular Hemoglobin MCHC-Mean Corpuscular Hemoglobin Concentration RDW-Red Cell Distribution Width Starting with the RBC : We look at the relationship of the amount of hemoglobin to the size of the cell using mathematical comparisons we call Indices. There are 4 that are listed on a CBC. MCV measures the average size of the red cells MCH MCHC RDW: variation in The size of the red cells; INDICATES THE DEGREE OF ANISOCYTOSIS

Mean Corpuscular Volume (MCV) The average size (volume) of an RBC. MCV (in fL) = (hematocrit x 10) (rbc count [in millions/µL]) Normal values: 80-100 fL The MCV is a useful tool in the differential diagnosis of anemia Used to determine anisocytosis, size of rbc: microcytosis= < 80 fL; macrocytosis= >100 fL 1 femtoliter(fL)+ 10-15L

Mean Corpuscular hemoglobin (MCH) The average hemoglobin content of a RBC. Normal values: 26-34 pg. MCH (in pg) = hemoglobin x 10 rbc count (a picogram [pg] = 10-12 gram) MCH=15x10/5.0=30 pg=WNL

Mean Corpuscular Hemoglobin Concentration (MCHC) The percentage of a RBC's volume which contains hemoglobin. Normal values: Usually between 31-37%. MCHC may be decreased with severe iron deficiency anemia. MCHC [in g/dL] = hemoglobin [in g/dL] hematocrit [in L/L] CALCULATED AS: MCHC=MCH/MCV ( MCH FORMULA USES HGB; MCV FORMULAS USES HCT) WHAT % OF THE TOTAL AREA OF THE RED CELL IS OCCUPIED BY HEMOGLOBIN; How big is the central pallor? NORMAL VALUES MAY VARY DEPENDENT ON INSTITUTION; MORE LIKELY TO BE 33-36

RED CELL DISTRIBUTION WIDTH (RDW) Degree of Red Cell size variability in a blood sample Coefficient of variation of the size of the RBCs Expressed as % Derived from automated instruments that can directly measure the MVC Normal: 11-15 % RDW =SD of MCV x 100 Mean of MCV How do we use these measurements to reveal the state of the blood system? If RDW normal = homogenous population of cells RDW >14.5% = heterogeneous population of cells

Using the RBC Indices MCV reveals the average size of the RBCs RDW reveals a variation in size among the RBCs MCHC reveals how much of the cell is being taken up by hemoglobin Together can reveal anemia or physiologic disorders that affect quality of life Decreased MCV = small Rbc, microcytosis Increased MCV=Macrocytosis Increased RDW mean more diffrerent sized RBC; could mean younger rbc

Lab Language: Indices Anemia Microcytic Macrocytic Hypochromic normochromic Using the indices to classify anemia’s: decrease in hemoglobin affecting capability of carrying O2. Results from decresed RBC, decreased Hgb conc, abnormal Hgb Micro: smaller than 8o fL Macro: larger than 100 fL Hypo: less normal hemoglobin measurement Normo: within normal ranges

ERYTHROCYTOSIS Polycythemia vera Secondary Polycythemia -COPD -Inappropriate stimulation of erythropoietin, such as tumors Relative Polycythemia -dehydration, -severe burns RBC > upper limits of normal

ERYTHROPENIA (ANEMIA) Anemias - may result from: chronic or acute blood loss decreased synthesis increased destruction or decreased survival dilutional effect: postural (lower in recumbent position) overhydration A condition in which there is a decrease in hemoglobin in the blood and therefore in the amount of O2 reaching the tissues and organs. May be the result of a drcrease in the number of RBC (decreased cell mass), decreased hgb conc, or abnormal hgb

Anemia Classifications Microcytic, hypochromic Microcytic, normochromic Normocytic, normochromic Macrocytic, normochromic

NORMOCYTIC, NORMOCHROMIC ANEMIA MCV normal MCHC normal Examples: acute blood loss aplastic anemia most leukemia's bone marrow infiltration Normal looking RBC, Normal indices, decreased number of RBC circulating. Hemolytic anemia’s Increased plasma volume will result in NC/NC anemia (pregnancy)

MICROCYTIC, HYPOCHROMIC ANEMIA MCV decreased MCHC decreased Examples: iron deficiency thalassemia lead poisoning anemia of chronic disease

MICROCYTIC, NORMOCHROMIC ANEMIA MCV decreased MCHC normal Examples: mid-stage iron deficiency thalassemia Most common type; Fe def has several possible causes: decreased Fe intake( diet or malabsorption), increased Fe loss(chronic bleed), increased Fe requirement(pregnancy,etc). Must determine cause so as to treat properly to correct.

MACROCYTIC, NORMOCHROMIC ANEMIA MCV increased MCHC normal Examples: folate deficiency vitamin B12 deficiency pernicious anemia Primarily megaloblastic anemias, Vit B12 or folic acid def; Larger, more immature RBC produce MCV values of 120-140 fL Floic acid def more common than B12 def. Osberved when requirement is increased, pregnanc;y, infancy, hemolytic anemias, hyperthyroidisms

Hemoglobin & Hematocrit Normal Ranges Cord blood: - Hb - 16.5 ± 3 g/dl - Hct - 51 ± 9 % 0.5-2 years: - Hb: 12.0 ± 1.5g /dl - Hct - 36 ± 3 % 12-16 yrs: Female: -Hb 14.0 ± 2 g/dl -Hct 41 ± 4% Male: -Hb 14.5 ± 1 g/dl - Hct 43 ± 6%

Hemoglobin & Hematocrit Adult Normal Ranges Male: Hb 15.5 ± 2 g/dl Hct 47 ± 6% Female: Hb 14.0 ± 2 g/dl Hct 41 ± 5%

Used for quality control Hb X 3 = Hct ± 3% RBC X 3 = Hb RULES OF THREE Used for quality control Hb X 3 = Hct ± 3% RBC X 3 = Hb Hct X 100,000 = RBC Review the CBC to make sure the results reflect a good test. The technologt will do this on every cbc that is done.

Complete Blood Count White Blood Count (WBC) Red Blood Cell Count (RBC) Platelet Count (Plt) Hemoglobin (Hb or Hgb) Hematocrit (Hct) Red Cell Indices (MCV,MCHC,MCH) Red Cell Distribution Width (RDW) Differential Count (Diff) Most common test done; basic to health of individual; consists of very specific counts of formed elements of the blood. EVALUATION OF SIZE AND SHAPE of RBC Can be done without the differential but must indicate that you want a CBC no diff; most instruments give a diff automatically

CBC 1 RBC 5.25 x 10[12]/L HGB 15.4 g/dL HCT 46.1 % MCV ______ MCH _____ MCHC ______ RDW _____ Lets take what we learned today and apply it to a situation. Do the rules of three apply? Calculate the indices. What can you say about these patient’s CBC? Make these calculations and let’s see what it tells us

CBC 1 RBC 5.25 x 10[12]/L HGB 15.4 g/dL HCT 46.1 % MCV 87.9 fL MCH 29.3 pg MCHC 33.4 g/dL RDW 12.2  

CBC 1

CBC 2 RBC 3.71 x 10[12]/L HGB 5.9 g/dL HCT 20.9 % MCV ______ MCH ______ MCHC ______ RDW ______ Do the rules of three apply? Calculate the indices. What can you say about these patient’s CBC? Make these calculations and let’s see what it tells us

CBC 2 RBC 3.71 x 10[12]/L HGB 5.9 g/dL HCT 20.9 % MCV 56.2 fL MCH 15.9 pg MCHC 28.3 g/dL RDW 20.2

CBC 2

CBC 3 RBC 3.36 x 10[12]/L HGB 10.9 g/dL HCT 31.2 % MCV _______ MCH ________ MCHC ________   Do the rules of three apply? Calculate the indices. What can you say about these patient’s CBC? Make these calculations and let’s see what it tells us

CBC 3 RBC 3.36 x 10[12]/L HGB 10.9 g/dL HCT 31.2 % MCV 92.8 fL MCH 32.4 pg MCHC 34.9 g/dL  

CBC 3

CBC 4 RBC 1.26 x 10[12]/L HGB 5.7 g/dL HCT 16.3 % MCV ________ MCH ________ MCHC ________ RDW 18.1 Do the rules of three apply? Calculate the indices. What can you say about these patient’s CBC? Make these calculations and let’s see what it tells us

CBC 4 RBC 1.26 x 10[12]/L HGB 5.7 g/dL HCT 16.3 % MCV 130 fL MCH 45.2 pg MCHC 34.9 g/dL

CBC 4 MACROCYTOSIS