abc of c.b.c

ABCS OF CBC

Dr.abdulfattah alshenawiMBBch,Msc,Mrcs(Ireland)

Cons,general surgery(M.G.H)

OBJECTIVES

Be able to interpret (CBC) reports

Recognize common blood disorders

Know when to request hematology consultation

REMEMBER!

WHY DO WE NEED CBC?

Screening? Diagnosing clinical situations. Monitoring disease& effect of

treatment Prior to major procedure.

BLOOD COMPONENTS

57% Plasma

1% Buffy coat – WBC

42% RBCS

FROM WHERE BL.CELLS?

o All Blood Cells made in bone marrow.o Bone Marrow is the spongy centers of

bones sometimes seen in cuts of meat

oStem cells are young cellsoThey get “drafted” as RBCs, WBCs or platelets depending on the body’s needs

LOOK FOR WHAT?

CBC REPORT

RESULTS OF LAB.TESTS

• May be affected byActivity

DietStress

Geographymedications

Time of the day

CONCEPT OF NORMAL

REF.RANGE

PANIC VALUE

ERYTHROCYTES

WBCS DIFF.

ASSESS ERYTHROCYTE ABNORMALITIES HB% gm%(13-17gm%)

HCT volume of blood occupied by RBCS(35-45%)

MCV average volume of individual RBC.(80-100fl) RETIC % of immature RBCs in blood(1-2%)

RDW (10-15%)

RBCS. COUNT IS ADDITIONAL TO DIAGNOSIS

RBCSX3=HBX3=HCT (If not -indicates micro or macrocytosis or hypochromia).

PBS is additional privilge.

depend on both total red cell

mass and plasma volume

BM activity

Degree of anisocytosis

HCT

RETICULOCYTE

50 100 200 fl

RBC

%

MCV&RDW width" refers to the width of the

volume curve (distribution width), not the width of the cells.

Correlate with the degree of anisocytosis

normal RDW+ mic. Anaemia thalassemia high RDW + mic.anaemia iron deficiencyhigh RDW + mac.anaemia vit B12&folate def.high RDW + norm.anaemia hge

ANAEMIA(PATHOPHYSIOLGY)

PROCEED TO INTERPRETATION

Is the pt. anaemic? Low HB = anaemia Look to MCV Normal =normocytic anaemia?A. Acute hge= normal Hct B. explore for the site by HX&PE(shock,revealed or

concealed hge)C. Haemolysis= high retic., ( high LDH,low haptoglobin,& indirect

hyperbilirubinaemia,jaundice) Acute haemolysis, incompatible blood trans. Chronic haemolysis (Hbpathy,enzymopathy, membranopathy)

HAEMOLYSIS

Haemoglobinuria is differentiating between IV&EV haemolysis

HB

A B

AB

A

A

DELTA

DELTA

A

A

GAMMA

GAMMA

HBAA2B2

HBA2A2D2

HB FA2 G2

Normal variant of HB

QUALITATIVE VS QUANTITATIVE

HBSDef.B

Subunit

Sickle cellanaemia

B, thalassDec. B chain

A.ThalassDec,A chain

Abnormal HB

HEREDITARY SPHEROCYTOSIS

MEMBRANOPATHIESRBCS SHAPE

PROCEED MORE!! Low MCV= microcytic anaemia What THIS?1) Normal or low retic=do serum

ferritin IDA (low ferritin) ACD (high ferritin) (low TIBC) Thalas (normal ferritin) SA (high ferritin) (normal

TIBC)2) High Retic= Search for signs of haemolysis

MICROCYTIC ANAEMIA Thalasemia I.D.A S.A A.C.D

MICROCYTIC ANAEMIA

THINK OF DESTURBED HB SUBSTRATES.

ACD

MICROCYTIC ANAEMIA

MICROCYTIC ANAEMIA CHECK RBCs• thalassemia

• ACD,SA,IDA S.ferritin

Low in IDA

High in SA,ACD

WHAT IF? High MCV= macrocytic anemia Think of neutritional deficiency1) Vit B12 2) Folic acid Do what???????

PBSPBS

1) non megaloblastic macroreticulocyte,rounded macrocytes (alcohol liver dis.) RFT,LFT(GGT)TFT

MACROCYTIC ANAEMIA2)MEGALOPLASTIC• 85% pernicious anaemia.(+ve AB for

IF)• Macroovalocyte&

hypersegm.neutrophil

Rule out medic

Check vit B12&FOLI

C

DEC.folate

Norm.B12

CONSIDER folate def.

Dec.B12Norm folate

Check MMA

Increase MMA

Confirm def.

Both normal

Consider alcohol.liver,medhypothyroidism

MCV#

Microcytic

MCV

Normocytic Macrocytic

Iron Deficiency IDAThalassemiasHemoglobinopathiesSideroblastic Anemia

Hemolysis

Hemorhage

Vit B12

Folic acid

Alcohol liver dis.

drugs

POLYCYTHEMIA

POLYCYTHEMIA VERA

COMPLICATIONS OF POLYCYTH.

CBC REPORT

CBC REPORT

CBC REPORT

CBC REPORT

WBCS

WBCS

Different typesDifferent life spanDifferent functions

Different sizes

NORMS OF LEUKOCYTES TLC 4-11000/cmm DLC neutrophil(60%) lymphocyte(30%) eosinophil(6%) monocyte(3%) basophil(1%)

WBCS DISORDERS PROLIFERATIVE OR LEUKOPENIA PROLIFERATIVE MAY BE REACTIVE OR

NEOPLASTIC DIFFERENTIATION BENIGN FROM

MALIGNANT DISORDERS IS OF UTMOST IMPORTANCE.

DEFINITIONS Leukocytosis increase

WBCs.>11000 Leukopenia decrease

WBCs.<4000 Granulocytosis neutrophilia Granulocytopenia

neutropenia<2000/cmm Agranulocytosis

neutropenia<500/cmm

EVALUATION OF TLC&DLC Leukocytosis

(neoplastic &prolifrative)

Identify infection,inflammation,&tissue damage

More than100000/cmm. seen in leukaemia.

Stress & steroids are reversible soon

NEUTROPHILIA Morphology. Granulocytosis. Early in acute infection x

agranulocytes!! Shift to left indicate overwhelming

infections.(bands or stabs) Shift to right indicate tissue

damage or necrosis.(segs.)

NEUTROPHILIA

Red flagsperson particularly unwellseverityrate of change of neutrophiliapresence of left shift

EOSINOPHILIA. Elevated in parasitic infestations&

allergy. Intestinal parasite,and

toxoplasmosis. Asthma &hay fever.

BASOPHILIA. Most uncommon. Seen in systemic hypersensitivity. Thorough allergy history should be

obtained before any surgical procedures.

MONOCYTOSIS. Late in acute infections Chronic infections as TB&SBE. Hodgkin,s lymphoma,fungal Monocytopenia(aplastic

anaemia,glucocorticoid ,&hairy cell leuk).

LYMPHOCYTOSIS. Origin& maturation Types . Acute viral infections CMV,INF.MONONUCLEOSIS,MMR EARLY H.I.V CLL. Lymphopenia in HIV& AIDS.(CD4

count <200)

LEUKOPENIA. Decrease production(CT,RT.). Neutropenia (aka,granulocytopenia) Neutrophil<2000/ul. Bone marrow exhaustion(prolonged

severe inf Increased

destruction(hyperspleenism) Antithyroid,antidepressant,NSAID. Protect pt.,avoid surgery if

possible.

LEUKOPENIA(CONT.) Severe

neutropenia(aka.agranulocytosis) Neutrophil,< 500/ul. Pt.is predisposed to serious,G-

ve,G+ve,& fungal infections. Red flags

person particularly unwell lymphadenopathy,

hepatosplenomegaly

CLINICAL IMPLICATIONS Leukocytosis signals infections. Leukopenia signals BM depression. Neutropenic precautions Care of invasive maneuvres. Avoid crowding& recent

vacc.children Avoid steroids&antipyretics. Avoid raw &uncooked foods. Reporting high temp.

PLATLETS Outpt . VS inpt. Norms:150-400.000/ml TPO is the primary regulatory protein in the

production of platelets

STRATIFYING LEVELS OF THROMBOCYTOPENIA

The primary reason for evaluating thrombocytopenia is to assess the risk of bleeding and assess the presence of underlying disorders (TTP, HIT etc.)< 20 000 increased risk of bleeding20 to 50000 rarely have increase risk of

spontaneous bleeding but increase risk of bleeding from procedures

50 to 100000 no increased risk of spontaneous bleeding and can undergo most procedures

DEFINITION Thrombocytopenia

is defined as a platelet count less than 150,000

2.5 percent of the normal population will have a platelet count lower than this

DIFFERENTIAL Pseudothrombocytopenia Decreased Production- suggested by:

other cytopenias normal sized/small platelets suggest a reduced

bone marrow response to need Increased Destruction- suggested by:

Microangiopathic blood picture (fragmented RBCs, high LDH)

Large platelets on smear Associated autoimmune disease

APPROACH History, FH,MED H, PBS TTP+lymphocytosis,neutrophilia

( infection) Isolated TTP(DIC,ITP,HIT,DITP) Giant plat.(hereditary TTP) Blasts& nucleated RBCS(BM disorder) Schistocytes(HUS,DIC)

PHYSICAL EXAM Petechiae Purpura — Ecchymoses The most common

cause of thrombocytopenia developing for the first time in an ICU patient is sepsis, accounting for one-half of the cases

Bone marrow suppression from infection

Platelet microaggregation

Production of toxins

Consumption of coagulation factors (DIC)

PSEUDOTHROMBOCYTOPENIA

If blood sample is inadequately anticoagulated, platelet clumps can be counted as WBC’s

0.1% of patients have EDTA dependent agglutinins

DECREASED PRODUCTION

Viral infections Direct megakaryocyte damage-HIV Post CT,RT Acquired bone marrow hypoplasia- Fanconi

anemia. alcohol toxicity B12 or folate deficiency

INCREASED DESTRUCTION

autoimmune destruction anti-platelet Abs(ITP,SLE)

Alloimmune destruction( posttransfusion)

Destination destruction(hypersplenism) Consumption (DIC ,TTP- HUS) HELLP in pregnant women Medications- heparin, valproic acid Infections- EBV, CMV, sepsis

y

PS.PENIA TRUE.PENIA Giant plt

Isolated TP

ITPHITDIC

Neutrophillymphocyt

Consider infection

Blast cellsNucleated

RBCS

1ry BM DISORDER

schistocyte

TTP/HUS/DIC

THROMBOCYTOPENIA

Hereditarythrombocy

tPBSPLT

clumbing

CBC IN ACUTE LEUKAEMIA AML Anaemia Leukocytosis Thrombocytopeni

a >20% blast in

PBS >80% blast in

BMA PUO+splenomeg

ally Auer rodes

ALL Anaemia Leukocytosis Throbocytopenia >20% blast in

PBS >80% blast in

BMA PUO,LN swelling

CBC IN CH.LEUKAEMIA CML Anaemia Leukocytosis+lt.shif

t Lymphocytosis Thrombocytopenia Basophilia splenomegally Philadelphia ch.

CLL Anaemia Leukocytosis+lt

shift Lymphocytosis Thrombocytosis Basophilia Splenomegally B cell CD19,,CD5

flow cytometry

QUIZ 1?

QUIZ 2 ?

QUIZ 3?