Interpretation of the Complete Blood Count (CBC)

Interesting Blood Facts

Average human being has about 5 Liters of blood 2.25 L (45%) consists of cells 0.037 L (1.6%) are leukocytes - an amount which would fit into a bartender's jigger total circulating platelet volume is only 0.0065 L (just over a teaspoonful) rest (55%) is plasma

Complete Blood Count (CBC)

One of the most commonly ordered tests Provides information on kinds and numbers of cells in the blood
Red blood cells White blood cells Platelets

Used to determine general health status and to screen for a variety of disorders
anemia, Infection Nutritional status Exposure to toxins

Whats In the CBC?

Red Blood Cells (RBCs) Hematocrit (Hct) Hemoglobin (Hgb) Mean Corpuscular Volume (MCV) Mean Corpuscular Hemoglobin Concentration (MCHC) White Blood Cells (WBCs) Platelets

Red Blood Cells (RBCs)

Also known as erythrocytes RBC = count of number of RBCs per cubic mm of blood Normal red blood cell values at various ages are:
Adults: (males): 4.6 - 5.9 million (Females): 4.2-5.4 million Pregnancy: slightly lower than normal adult values Newborns: 5.5 - 6 million Children: 4.6 - 4.8 million

Development of an Erythrocyte (RBC)

Start as blast precursors
in the bone marrow develop over a period of 5 days have nuclei

Released into the blood as reticulocytes (also called shift cells") Reticulocytes change into erythrocyte in one day Erythrocyte normally lasts 120 days - has no nuclei Erythrocyte normally destroyed in the reticuloendothelial system

Shift Cells

Reticulocytes

Causes of Increased RBCs

Increase in RBCs = polycythemia Normal RBC increases:
High altitudes Intense physical training Some drugs (gentamicin & methydopa) Smokers

Pathologic RBC increases:

Polycythemia vera Secondary polycythemias

Causes of Decreased RBCs

Lower than normal RBCs Anemia
Decrease in number of RBCs Decrease in Hgb content Decrease in both RBC numbers and Hgb

Can be due to a large number of causes

Hemorrhage Abnormal destruction of RBCs Lack of substances to produce RBCs Bone marrow suppression

Hematocrit
Also known as Hct, crit, or packed cell volume (PCV) Percentage of RBCs in plasma When spun in centrifuge, WBCs and platelets rise to top (buffy coat) Normal values
Adults: (males): 45-52%, (females): 37-48% Pregnancy: decreased hematocrit, especially in the last trimester as plasma volume increases Newborn: up to 60% Children: varies with age

Hemoglobin
Oxygen-carrying capacity directly related to Hgb concentration, not number of RBCs Also serves as pH buffer in extracelluar fluid Often used to determine anemia Normal Hgb values:
Adult: (males): 13 - 18 gm (Females): 12 - 16 gm Pregnancy: 11 - 12 gm Newborn: 17 - 19 gm. 77% of this value is fetal hemoglobin, which drops to approximately 23% of the total at 4 months of age Children: 14-17 gm

Causes of Increased Hgb

Found in any condition in which RBCs increase Examples:
Polycythemia vera Severe burns Heart failure COPD

Causes of Decreased Hgb

Normal adult Hgb has only a small percentage of fetal Hgb (HgbF) RBCs with abnormal Hgb are more fragile, and are damaged or destroyed easily Examples:
Thalassemia major - high amount of HgbF and abnormalities in hemoglobin synthesis Sickle Cell Anemia - abnormal type of hemoglobin known as sickle hemoglobin (HgbS)

Causes of Decreased Hbg (cont)

Normal RBCs but low Hgb Iron-deficiency anemia = hypochromic anemia
Often women (who menstruate) need more iron than men During pregnancy, women need more iron Physiological anemia of pregnancy last trimester, drop in Hgb due to increased plasma volume

Hgb: Critical Values

A hemoglobin value under 5 gm may cause heart failure A hemoglobin value over 20 gm may cause clogging of capillaries due to hemoconcentration

If Hgb Is Decreased
When a patient has a lower than normal hemoglobin, it is important to determine whether red blood cells are of normal size and if they have a normal concentration of hemoglobin. These measurements, known as erythrocyte or red blood cell indices, provide important information about various types of anemias.

Mean Corpuscular Volume

MCV measures the mean or average size of individual RBCs MCV = Hct/total RBC count Normal MCV values:
Men: 80-90 cubic microns Women: 82-98 cubic microns

If MCV is normal range = cells are called normocytic (ex: hemorrhage)

Causes of Increased MCV

Cells are macrocytic/larger than normal Examples
Pernicious anemia Folic acid deficiency

Causes of Decreased MCV

Cells are microcytic/smaller than normal Examples:
Iron deficiency anemia Lead poisoning Thalassemia major and minor

Mean Corpuscular Hemoglobin

MCH Measures the amount of hemoglobin present in one RBC MCH = Hgb/total RBC count Reported by a very small weight called a picogram (pg)

Mean Corpuscular Hemoglobin Concentration

MCHC Measures the proportion of each cell taken up by hemoglobin (reported in %) MCHC = Hgb/Hct x 100

MCH & MCHC

The MCH and the MCHC are used to assess whether red blood cells are normochromic, hypochromic, or hyperchromic An MCHC < 32% or MCH < 17 pg indicates that the RBCs are deficient in Hgb concentration This situation is most often seen with iron deficiency anemia.

Anemias Classified By Erythrocyte Indices

MCV, MCH and MCHC normal - normocytic, normochromic anemia (most often caused by acute blood loss) Decreased MCV, MCH, and MCHC - microcytic, hypochromic anemia (most often caused by iron deficiency) Increased MCV, variable MCH and MCHC macrocytic anemia (most often caused by Vitamin B12 deficiency [due to pernicious anemia] and folic acid deficiency)

WBC Characteristics
Lifespan ranges from 13-20 days Destroyed in lymphatic system Lifecycle of WBC Develop in bone marrow When immature WBCs released into blood they are called bands or stabs

White Blood Cells (WBCs)

2 main groups Granulocytes
Neutrophils Eosinophils Basophils

Non-Granulocytes (agranulocytes)
Lymphocytes Monocytes

WBCs - Granulocytes
Physical characteristics All have granules in cell cytoplasm Multilobed nucleus Often called polymorphonuclear leukocytes or "polys

Neutrophils
Also known as neutrophil polymorphonuclear leukocytes or polymorphonuclear neutrophils (PMNs) Nuclei of neutrophils appear to be segmented, so often called segmented neutrophils or "segs" Leukocytes fight infection through a process known as phagocytosis Respond to chemotactic signals

Phagocytosis

Neutrophils (cont.)
Named because they are not well stained by either eosin, a red acidic stain, nor by methylene blue, a basic or alkaline stain Body's primary defense against bacterial infection and physiologic stress Normally, most of the neutrophils circulating in the bloodstream are in a mature form, with the nucleus of the cell being divided or segmented Nucleus of less mature neutrophils is not segmented, but has a band or rod-like shape

Neutrophils (cont)
Leave capillaries by a complex process (margination) Several mediators are involved:
substances produced by micro-organisms cells participating in the inflammatory process interleukin-1 histamine C3a and C5a acute phase proteins ex: C-reactive protein (CRP)

Neutrophils

Increased Neutrophils
Acute bacterial infection - increase in both total number of mature neutrophils and the less mature bands or stabs Inflammatory processes During physical stress Tissue necrosis after burns or MI Granulocytic leukemia

Shift to the Left

Used to determine an inflammatory process, such as appendicitis or cholecystitis Term is a holdover from days in which lab reports were written by hand
Bands or stabs (immature forms) were written first on the left-hand side of the laboratory report

Today, the term "shift to the left" means that the bands or stabs have increased, indicating an infection in progress

Example of a Shift to the Left

A patient with acute appendicitis might have a "WBC count of 15,000 with 65% of the cells being mature neutrophils and an increase in stabs or band cells to 10%". This report is typical of a "shift to the left", and will be taken into consideration along with history and physical findings, to determine how the patient's appendicitis will be treated.

Decreased Neutrophils
Known as neutropenia Some diseases do this, such as:
typhoid fever Brucelosis many viral diseases
Hepatitis Influenza Rubella Rubeola Mumps

Overwhelming infection can deplete bone marrow production

Decreased Neutrophils (cont.)

Medications can decrease neutrophils Anti-neoplastic medications Some antibiotics Lithium (psychotropic drug) Phenothiazines Tricyclic antidepressants

Eosinophils
Primary purpose is to combat large parasites such as helminths (damage parasite membrane) Attach via C3b receptors Release various substances from their granules:
major basic protein (MBP) cationic proteins Peroxidase arylsulphatase B phospholipase D histaminase

Basophils
Non-phagocytic cells Release numerous compounds from their basophilic granules in cytoplasm Major role in allergic responses, particularly type I hypersensitive reactions

WBCs Non-Granulocytes
Do not have granules in cell granulocytes Have non-lobular nuclei Sometimes called mononuclear leukocytes

Lymphocytes
Produced in primarily in bone marrow and thymus
B-cells = if achieved immune competence in bone marrow T-cells if achieved immune competence in thymus

Organized lymphoid tissue elsewhere is known as secondary lymphoid tissue

lymph nodes Adenoids Tonsils mucosa associated tissue (MALT)

Lymphocytes (cont.)
Lymphoid organs receive antigens from the tissues and mucosal surfaces Antigens that succeed in invading the blood stream are intercepted in the spleen Also respond to presented antigens by the production of antibodies (by B cells) or lymphokines (by T and B cells)

Normal Lymphocyte

Monocytes
Circulate in blood prior to emigration into tissues Special names, depending on organ location
Liver = Kupfer Cells Brain = Microglia Kidney = Mesangial Cells Bone = Osteoclasts Other organs = tissue macrophages

How Are WBCs Reported?

Total number of WBCs in a milliliter of blood
Reported as an absolute number of "X" thousands of white blood cells Percentage of each of the five types of white blood cells Test is known as a differential or "diff" and is reported in percentages

Normal WBC Values

Total WBC: 5,000 - 10,000 Bands or stabs: 3 - 5 % Granulocytes (or polymorphonuclears) Neutrophils (or segs): 50 - 70% relative value (30007000 absolute value) Eosinophils: 1 - 4% relative value (50-400 absolute value) Basophils: 0.5% - 1% relative value (25-100 absolute value) Agranulocytes (or mononuclears) Lymphocytes: 25 - 40% relative value (1700-3400 absolute value) Monocytes: 2 - 8% relative value (200-600 absolute value)

Platelets
Cell fragments formed in the bone marrow Primary function is to help blood clot Lifespan is 9-12 days in bloodstream Normal values range between 150,000 and 450,000 A report of "adequate platelets" implies that there is at least one platelet for every 20 red blood cells.

Causes For Decreased Platelets

Decreased production in bone marrow due to lack of building materials or bone marrow dysfunction Excessive platelet use/destruction Hemophilia Liver Disease

Thrombocytopenia
Caused by platelet destruction or impaired production Ex: thrombotic thrombocytopenic purpura and disseminated intravascular coagulation (DIC), platelets are used up rapidly

Critical Values for Platelets

Normal: 150,000-450,000 Thrombocytopenia if drops below 50,000 If drops < 20,000, at high risk for spontaneous bleeding that could cause death

Signs of Bleeding Due to Low Platelet Count

Easy bruising Unusual or heavy nosebleeds Hematuria Black, tar-like stools or frank bleeding with bowel movements Hematemesis Syncope or visual disturbances due to intracranial bleeding Gingival bleeding Heavy vaginal bleeding

Blood Collection Tubes

Tube Top Color
Red Purple Green Blue Black

Contains
Nothing EDTA heparin

Used For
Electrolytes, flow cytometry CBC CBC (2nd choice) Coagulation studies (PT, PTT) Lead poisoning evaluation

How Do You Chart a CBC?

Hgb WBC Hct Platelets, differential, etc

12.1

10.6 31.6 578 NE 71.1 LY 15.9 MO 3.3 EO 0.5 BA 8.7

Blood Slides

Identify the segmented neutrophil, band neutrophil, lymphocyte, monocyte, eosinophil, basophil, and platelet in the image below:

See anything interesting on this slide?

Target Cells