Automated CBC Parameters

and

Quality Control
Joanna Ellis, MLS(ASCP)

The Automated Complete Blood Count

Most common test in the Hematology lab. Main Components of the CBC:
Cell counts Hgb RBC indices WBC differential absolute values and percent Fatigue Weakness Infection Inflammation Bruising Bleeding

Indications for CBC:

CBC Parameters
PARAMETER WBC RBC HGB UNIT OF REPORTING X 103 /L X 106 /L g/dL COMMON METHOD OF DETERMINATION Impedance count X calibration (cal) factor Impedance count X calibration factor Colorimetric absorbance in proportion to hemoglobin From RBC histogram, #of RBCs X size of RBCs X cal constant OR Calculated: HCT X 10 RBC Calculated: RBC X MCV 10 Calculated: HGB X 10 RBC

MCV

fL

HCT MCH MCHC RDW Platelet WBC Diff

% Pg g/dL or % % X 103 /L Absolute: X103 /L Percent of WBC : %

Calculated: HGB X 100 HCT Impedance (from histogram) Impedance count X cal factor Light Scatter , flow cytometry

M77221

CBC Adult Reference Ranges

Parameter WBC RBC HGB HCT MCV MCH MCHC RDW PLT MPV Adult Reference Range 4.5-11.0 X 103/L Male: 4.5-5.5 X 106 /L Female: 4.0-5.0 X 106 /L Male: 14-17.4 g/dL Female: 12.0-16.0 g/dL Male: 42-52% Female: 36-46% 80-100 fl 28-34 pg 32-36 g/dL or % 12.0-14.6% 150-450 X 103 /L 6.8-10.2 fl

Linearity (Reportable Range)

Instruments are calibrated for each analyte with a range that is clinically relevant. With concentrations above or below the reportable range or Linearity range, the result does not correspond with the calibration curve in linear fashion. Results outside of linearity are NOT acceptable. Linearity ranges vary by instrument.
Example:
Parameter WBC Coulter STKS 0.0 -99.9 X 103 /L Advia 0.02-400 X 103 /L

Advia Linearity Instrument Codes

Code Cause Action Indicated Dilute 1:2 and rerun. Continue further dilutions until result is within linearity

+++++

Result exceeds reportable range

Result higher than the laboratory set patient high action limit

Review Result

Result is lower than the laboratory set patient low action limit

Review Result

CBC Quality Control

Commercial Controls: 3 levels (low, normal, high) Values stored in instrument computer Levey-Jennings graph generated and stored for each parameter Mode to Mode QC: Most automated hematology instruments have a primary and secondary mode of sample aspiration. Controls must be run on BOTH and correlate. Primary=Automated or Closed Secondary=Manual or Open Delta Checks When the Laboratory Information System (LIS) and the instrument are interfaced (connected) delta checks are conducted by the LIS on select parameters. Current values compared to most previous result Differences greater than the limits set within the LIS are flagged

WBC Parameter Interfering substances and Implications

Test Name Interfering Agent Clinical Implications

Unusual RBC abnormalities that resist lysis Nucleated RBCs White Fragmented WBCs Blood WBC Unlysed particles greater than 35 fL Cell Very large or aggregated plts Count HIGH: >11.0 X103 /L Specimens containing fibrin, cell Infections fragments or other debris (esp Inflammation pediatric/oncology specimens cancer, leukemia

LOW <4.5 X103 /L some medications (such as methotrexate), some autoimmune conditions some severe infections bone marrow failure

RBC Parameter Interfering substances and Implications

Test Name Interfering Agent Clinical Implications LOW: Male: < 4.5 X 106 /L Female: < 4.0 X 106 /L Anemia

RBC

Red Blood Cell Count

Very high WBC count (greater than 99.9) High concentration of very large platelets Agglutinated RBCs, rouleaux will break up when Istoton is added RBCs smaller than 36 fL Specimens containing fibrin, cell fragments or other debris (esp pediatric/oncology specimens

HIGH: Male: > 5.5 X 106 /L Female: > 5.0 X 106 /L Polycythemia vera, fluid loss due to diarrhea, dehydration, buns

HGB Parameter Interfering substances and Implications

Test Name Interfering Agent Clinical Implications LOW: Male: <14 g/dL Female: <12.0 g/dL Anemia HIGH: Male: > 17.4 g/dL Female: >16.0 g/dL Polycythemia vera fluid loss due to diarrhea, dehydration, burns

HGB Or Hb

Very high WBC count Severe lipemia Heparin Certain unusual RBC abnormalities Hemoglobin that resist lysing Anything that increases the turbidity of the sample such as elevated levels of triglycerides High bilirubin

HCT Parameter Interfering substances and Implications

Test Name Interfering Agent Clinical Implications LOW: Male: <42% Female: <36% Anemia HCT Hematocrit Known factors that interfere with the parameters used for computation, RBC HIGH: and MCV Male: >52% Female: <46% Polycythemia vera fluid loss due to diarrhea, dehydration, burns

MCV Parameter Interfering substances and Implications

Test

Name

Interfering Agent

Clinical Implications

Very high WBC count High concentration of very large Mean platelets Corpuscular MCV Agglutinated RBCs (Cell) RBC fragments that fall below the 36 fL Volume threshold Rigid RBCs

LOW: <80 fL Iron deficiency anemia Thalassemia HIGH: >100 fL B12 Folate Deficiency

RDW Parameter Interfering substances and Implications

Test

Name

Interfering Agent

Clinical Implications

Very high WBC High concentration of very large or Red Cell clumped platelets RDW Distribution RBCs below the 36 fL threshold Width Two distinct populations of RBCs RBC agglutinates Rigid RBCs

HIGH: >14.6% Mixed population of RBCs Immature RBCs tend to be larger

Plt Parameter Interfering substances and Implications

Test Name Interfering Agent Clinical Implications LOW: < 150 X 103 /L Bleeding Wiskott-Aldrich, Bernard-Soulier Systemic lupus erythematosus Pernicious anemia Hypersplenism (spleen takes too many out of circulation) Leukemia Chemotherapy HIGH: >450 X 103 /L Benign idiopathic thrombocytosis Myeloproliferative disorders Polycythemia vera

Plt

Platelet Count

Very small red cells near the upper threshold Cell fragments Clumped platelets Cellular debris near the lower platelet threshold

WBC Differential Parameters Clinical Implications in Adults

Test
Neut %

Name
Neutrophil % In 100 WBC differential

Clinical Implications of LOW %

LOW: <40% Chemotherapy Severe infection

Clinical Implications of HIGH %

HIGH: >80% Bacterial infection Inflammatory disease Chronic myelogenous leukemia HIGH: >35% Viral infection Chronic or Acute Lymphocytic Leukemia HIGH: >10% Inflammatory disorders Myelomonocytic leukemia HIGH: >5% Parasitic infection Allergic reaction HIGH: >1% Allergic reaction to food Chronic inflammation

Lymph %

Lymphocyte %

LOW: <25% Lupus Later stages of HIV infection. LOW: <2% Bone Marrow Insufficiency

Mono %

Monocyte %

Eos %

Eosinophil %

Baso %

Basophil %

References
Harmening., Denise, Clinical Hematology and Fundamentals of Hemostasis, 3rd edition, pp. 593-599. Turgeon, Mary Louise, Clinical Hematology - Theories and Procedures, 3rd edition, pp373, 376-382. Rodak, Bernadette, Diagnostic Hematology, 1st edition, p.605-606. Coulter STKS Operating Manual McKenzie, Shirlyn, Clinical Laboratory Hematology, 2nd edition,pp 813-829. "Complete Blood Count: The Test." Lab Tests Online: Welcome! American Association for Clinical Chemistry, 18 June 2010. Web. 13 Sept. 2010. <http://www.labtestsonline.org/understanding/analytes/cbc /test.html#how>. "WBC Differential Count: The Test." Lab Tests Online: Welcome! American Association for Clinical Chemistry, 18 June 2010. Web. 13 Sept. 2010.http://www.labtestsonline.org/understanding/analytes/dif ferential/test.html#what>.