Exam Two Heme

Define reference range.

range or interval where 95% of values in the reference population fall into

What four physical factors listed in your PowerPoint affect the concentration of reference ranges?

a. Age
b. Sex
c. Race
d. Geological location

The term pathological relates to changes that are a result of \___________ or \_________.

disease, injury

Laboratory testing begins with (screening/confirmatory) tests and then based on these results physicians can determine if further (screening/confirmatory) testing is needed. (Circle the best answer for each choice).

screening, confirmatory

In the Complete Blood Count (CBC), what parameters are measured?

- RBCs
- WBCs
- Platelets
- Hematocrit
- Hemoglobin

In the CBC, what parameters are calculated? Write out the abbreviations for each and give a brief description of what is being measured.

a. MCV\= mean cell volume, average size or volume of the RBC
b. MCH\= Mean cell hemoglobin, average weight of hemoglobin in RBC
c. HCHC\= Mean Cell Hemoglobin Concentration, average concentration of Hemoglobin in RBC

Write the equation for MCV

(Hematocrit/ RBC count)*10\=

Write the equation for MCH

(Hemoglobin/ RBC Count)*10\=

Write the equation for MCHC

(Hemoglobin/Hemocrit)*100\=

Mean Cell Volume (MCV) Ranges

MCV\> 100fl: macrocytic
MCV< 80fl: microcytic
Normal: 80-100fl: normocytic

Mean Cell Hemoglobin (MCH) Ranges

27-32 pg

Mean Cell Hemoglobin Concentration (MCHC)

What interference is generally associated with MCHC \> 36%?

Lipemia

What is the red cell morphology generally associated with an MCHC \> 36%?

spherocytes

What tests are included in the Hemogram?

WBC, RBC, Hbg, Hct, Platelet

The CBC is considered a confirmatory test. T/F

F

Describe the "Rule of 3" using the relationship between hemoglobin and hematocrit.

Hemoglobin should match the Hematocrit, Hemoglobin*3\= Hematocrit +/- 3

Write the reference ranges for the CBC measured testing parameters:

- WBCs, reference range \= 5,000 - 10,000/microliters
- RBCs, reference range \= 4 - 6 million/microliters
- Platelets, reference range \= 150,000 - 400,000/microliters
- Hemoglobin Determination \= 12 - 16 g/dl
• Hematocrit \= 36 - 48%

What is the Neubauer Hemacytometer used for?

Used for manually counting red and white cells in body fluids.

In the counting chambers, the four outside corner squares are used to count which type of cells?

white blood cells

How many squares are within the innermost square? What cells are these squares used to count?

25 total squares, Counting RBC

What diluting fluids are used in manual WBC counts?

Acetic Acids: 3%
Hydrochloric Acid: 0.1 N
Turks Diluting Fluid:

What is the purpose of the acids used in manual WBC cell counts?

Turks Diluting Fluid:
- Glacial Acetic Acid: lyses the RBC
- Aqueous Gentian Violet: stain the sample
- Distilled Water: Dilute the blood sample and create a consistent medium

What is the purpose of the Aqueous Gentian Violet in the Turk's solution?

stains the WBC

How many mm are the squares in the grid of the Neubauer Hemacytometer?

nine large squares, which are divided into 16 smaller squares.

Write out the manual cell calculation in the space below.

(number of cells *Dilution factor*Depth Factor(10))/ number of of 1mm squares counted\=

WBC Normal Range

5,000-10,000 microliters

List the 3 variations that can cause a normal increase in WBC counts.

Exercise, Stress/anxiety, After eating a meal

What 2 variations were listed in your PowerPoint lecture that decrease WBC counts?

Race, diurinal variations

What were the three diluting fluids listed for manual RBC counting?

Hayem's, Gower's Isotonic Saline

In performing a manual RBC count, how many squares are generally counted in the centermost square?

5

Write out the calculation below if you had an average of 320 RBCs from counting both sides of the hemacytometer in 5 of those squares in the center 1 square.

320*

Write the normal RBC reference ranges for:

Newborn: 5.0 -6.5 million microliters
Male: 4.4-6.2 million microliters
Female: 4.2-5.4 million microliters

What five variables can cause a normal increase in RBC counts?

Age, Exercise, Gender, Altitude, Dehydration, Diurinal Variations

Explain why the RBC count increases in higher altitudes.

The body's way of adapting to the lower oxygen levels present at higher elevations

What is the Coulter principle?

a. Cells, suspended in a conductive fluid and flowing through a small aperture, detected, counted and measured by the changes in electrical resistance produced by those cells.

Describe the functions the hematology analyzer uses to measure hemoglobin and perform cell counts.

- DC Detection Method (Cell Count and size): Specific blood sample is aspirated, diluted, and sent to the transducer. The transducer causes a change in the current resistance, which is detected as electric pulses that indicate the cell size and are recorded on a Histogram as tiny dots.
- Non-Cyanide Hemoglobin Analysis Method (Hemoglobin): Our analyzer used this method. This method can rapidly convert blood hemoglobin to oxyhemoglobin and has the capability of analyzing methemoglobin

Define throughput

the amount of samples the instrument can carry in an hour

How many samples per hour can the KX-21N process?

60 samples/hour

Define carryover.

The transport of a quantity of analyte or reagent from one specimen reaction into and contaminating a subsequent one

What is coincidence?

statistical correction for cells going through the aperture more than one at a time.

Define the linearity range of values?

reportable range of values.

From the list of components, which reagent was the:
- Diluent:
- Detergent:
- WBC/HGB Lyse:

- CELLPACK
- CELLCLEAN
- Stromatolyser-WH

What is the purpose of calibrating the instrument prior to running quality control and patients?

to ensure that the instrument's measurements are accurate and aligned with known reference values.

Why do we run controls? How many levels of control are there? What intervals are quality control performed at?

monitor the accuracy and precision of a testing instrument. ensure that the instrument is functioning properly and producing reliable results.
- three levels of controls: low, normal, and high.
- performed at regular intervals, often daily, to catch any issues and ensure accurate testing.

What is the purpose of the background function on the hematology analyzer?

to measure and correct for any non-cellular particles or substances in a blood sample that could interfere with accurate cell counting and analysis

List the parameters that are measured.

a. WBC - direct count of cells
b. RBC - direct count of cells
c. HGB - direct measure of lysed blood
d. PLT - derived from platelet histogram using cells from 2 to 20 microns.
e. RDW - Red cell distribution width is the quantitation of anisocytosis. Displayed in a bell-shaped curve in a histogram.
f. MPV - Mean Platelet Volume

What type of specimen is tested in the hematology analyzer?

a. Whole blood: Well-mixed, Room temperature

Describe the steps of the workflow as the hematology analyzer processes a specimen. Start with aspiration and end with rinse.

a. Aspiration "Sucks" up the specimen.
b. Delivery: Pneumatics help pull the sample through the tubing to each area for testing.
c. Sensing: Each area senses the sample as it moves through the tubing and testing areas.
d. Analysis: Performs the function of hemoglobin lyses and cell count of the specimen ,prints result
e. Background and Rinse: "Spits" out the waste and cleans itself by flushing the diluent through the sample after every "run".

What are the linearity ranges for the following:

a. WBC: 1.0 - 99.9 x 103 /μl
b. RBC: 1.0-6.6x106/μl
c. Hgb: 0 to 20g/dl
d. MCV: 50 to 140 fl
e. PLT: 25 to 700x103/μl

How are results flagged by the instrument when indicating abnormal values?

a. Parameter flags - H or L (Determined by each lab and instrument)
b. Backlighting/ Highlighting of error
c. Delta checks
d. Analyzer flags (messages) for WBC, RBC. PLT

What are delta checks?

a type of quality control that detects sudden changes in a patients physiology or useful for identifying instrument errors or helpful in discovering misidentified patient samples

Name three analyzer flags that are displayed at the bottom of the report. Give two examples of each.

a. WBC: Leukocytosis, Atypical lymph
b. RBC: Dimorphic population: Microcytosis, fragments
c. PLT: Clumping. Thrombocytopenia/thrombocytosis, change in size and

From the table of analyzer limitations, what three parameters were +/increased in the presence of leukocytosis? Explain why these parameters are affected, describe what the affect is doing.

RBC: when the platelet clump together, the automated cell counters mistakenly identify clusters of white blood cells
HGB: turbidity cause it to look like wbc so the machine is unable to read the specimen
HCT: change in blood composition caused by the higher concentration of white blood cells in the blood sample.

From the table of analyzer limitations, what three parameters were affected by cold agglutinin? How were they affected (increased or decreased)? What does cold agglutinin look like and what is the defect?

WBC: Increase, cause RBCs to clump together so it seems like there is more wbc
RBC: Decrease, cause red blood cells (RBCs) to clump together so it seems like there is less
HCT: Decrease, cause RBCs to clump together so it seems like there is less blood volume

What was the only limitation listed in the table, for platelets? What was the error? Explain.

Platelet aggregation; Decrease the platelets, Platelet clumps on smear

What are the 5 questions the MLS must ask themselves when interpreting the results?

a. Are results within normal range?
b. Are results linear?
c. Are there any flags or codes present?
d. Do the HGB and HCT match? MCHC OK?
e. Do the results make sense? Possible?

From the list of corrections for limitations, which were associated with Pre-analytical errors?

Check patient label, Check tube for clots,Redraw specimen, Hemolysis

From the list of corrections for limitations, which were associated with Analytical errors?

Check instrument systems, Run correction procedures, Check reagents, Delta check, Check peripheral blood smear, Rerun, either whole or diluted.

From the list of corrections for limitations, which were associated with Post-analytical errors?

Review diagnosis and history of patient,

List the normal ranges for WBC

WBC: 5 to 10 x 10^3/ μl

List the normal ranges for RBC

RBC: 4 to 6 x 10^3/ μl

List the normal ranges for HGB (male and female)

HGB: Female 12 to 16 g/dl Male 13 to 17 g/dl

List the normal ranges for MCV

MCV: 80 to 100fl

List the normal ranges for MCHC

MCHC: 32-36%

List the normal ranges for PLT

e. PLT: 150 to 400 x10^3/μl

List the normal ranges for RDW

RDW: 11.5 - 14.5 %

What is the name of the graph that displays the distribution of WBC showing volume vs light scatter?

Scattergrams; used to visually represent the characteristics of different cell populations based on the way they scatter light and their size

What is the importance of reporting morphologies?

a. Gives the provider information regarding disease processes and can correlate to the severity of a disease/disorder process. The information can either confirm/lead to confirmational testing.
b. Morphology identification heavily relies upon the slide making process and the quality of the stain in order to appropriately identify morphologies and inclusions.
c. Identify physical abnormalities of RBCS in certain disorders, WBC and RBC inclusions, and diseases brought on by extremely high and low RBC and WBC counts.
d. Abnormalities in platelets can also be identified with a peripheral smear and associated to diseases/disorders.

Why are peripheral smears ordered?

a. The provider ordered it (typically seen with hematologists/oncologists).
b. Mets criteria from the analyzer flags, needs verified.
c. Pediatric patient, especially fingerstick draws.
d. A peripheral smear was specifically ordered to be sent to the pathologist

What patient identifiers are needed on slides when labeled?

- patient's full first and last name
- Accession/sample ID number

How long are slides kept?
a. 1 week
b. 1 month
c. 2 weeks
d. 3 days

b. 1 month

What is the name of the technique used when making a peripheral smear?

smear preparation.

What 3 factors help determine a good technique has been used?

- Using the right size blood drop
- The speed at which you spread the drop across the slide
- And the angle at which the drop is spread

Always mix the specimen before making a peripheral smear. T/F

T

What is another name for a Wright's stain?

Romanowsky Stain

What are the three components of a Wright's stain?

- Methylene Blue
- Eosin
- Gycerin

Which stain is used for performing manual differentials?

Wright's stain

What is a supravital stain?

a type of staining technique used to stain cells or tissues while they are still alive/shortly after death

What testing is it used for?

Retic counts and identification of other inclusions in suspected disease processes for confirmation.

Name two types of supravital stains?

- New Methylene Blue
- Brilliant Cresyl Blue

What cell components are stained by the supravital stain?

RNA, DNA, Heinz bodies, and Siderotic granules of the RBC.

What is wrong with your stain if it is orange? What causes this?

it is too acidic, caused by excess amount of buffer to stain, Insufficient staining time, Over-washing

What is wrong with your stain if it is purple? What causes this?

it is too basic/alkaline, caused by excess stain to buffer, not adequately rinsed.

Cell maturation. What does GEMM stand for?

g: granulocytes
e: erythroid cells
m: monocytes/ macrophage
m: megakaryocytes

Anisocytosis:
a. Define:
b. Describe or Draw cell shape:
c. Medical condition associated with:

a. the variation in the sizes of the RBCs. Correlation with the RDW of the CBC report, can be performed on the slides.
b. variation of RBC sizes so some small and some big
c. patients who have received a blood transfusion

Microcytes:
a. Define:
b. Describe or Draw cell shape:
c. Medical condition associated with:

a. < 80fl
b. smaller than a normal lymph
c. hemolysis, chronic diseases

Macrocytes:
a. Define:
b. Describe or Draw cell shape:
c. Medical condition associated with:

a. \>100fl
b. larger than a normal lymph
c. Vitamin B12 Deficiency & Folate (Vitamin B9) Deficiency:

Poikilocytosis:
a. Define:
b. Describe or Draw cell shape:
c. Medical condition associated with:

a. the variations in RBC shapes observed in the peripheral smear.
b. different shapes: round, oval, spikey
c. severe anemia, hemolytic states

Polychromasia:
a. Define:
b. Describe or Draw cell shape:
c. Medical condition associated with:

a. indicates immature erythrocyte
b. blue/purple color of rbc
c. Increased erythropoiesis, Hemolysis, Acute and chronic hemorrhage, Regenerative RBC process

Spherocytes:
a. Define:
b. Describe or Draw cell shape:
c. Medical condition associated with:

a. membrane defect in the RBC: decrease surface area to volume ratio, Defect in the proteins of the cell membrane.
b. dark red, round w/no central pallor
c. Hereditary Spherocytosis, Some hemolytic anemias (Immune & Autoimmune), Post-transfusion, Severe burns

Microspherocytes:
a. Define:
b. Describe or Draw cell shape:
c. Medical condition associated with:

a. tiny spherocytes, smaller than RBC, membrane defect in RBC
b. dark red, round w/no central pallor, smaller than RBC
c. Autoimmune hemolytic anemia, post-transfusion

Codocytes:
a. Define:
b. Describe or Draw cell shape:
c. Medical condition associated with:

a. target cell, caused by membrane defect, excess membrane cholesterol and phospholipids and decreased cellular hgb.
b. red or salmon colored, looks like a bullseye
c. Hemoglobinopathies, Thalassemia, Iron Deficiency Anemia (IDA), Splenectomy, Obstructive liver disease

Dacrocytes:
a. Define:
b. Describe or Draw cell shape:
c. Medical condition associated with:

a. shaped like a tear drop, result of the RBC squeezing and passing through the spleen or through fibers,
b. tear shaped, RBCs that are pinched, leaving a tail.
c. Primary myelofibrosis, Ineffective erythropoiesis, Megaloblastic anemia, Thalassemia

Elliptocytes:
a. Define:
b. Describe or Draw cell shape:
c. Medical condition associated with:

a. ovalocytes, Caused by abnormal cytoskeletal proteins, Cannot change back to normal shape.
b. irregular, elliptically shaped red cells
c. Hereditary elliptocytosis, Iron Deficiency Anemia (IDA)

Sickle Cell (Drepanocyte):
a. Define:
b. Describe or Draw cell shape:
c. Medical condition associated with:

a. caused by the presence of abnormal Hgb S, Polymerization of deoxygenated hemoglobin, Bc of deformity, the cell becomes inflexible and deforms as it passes through the microcirculation of the spleen.
b. Long elongated, crescent shaped cell with pointed ends, Hgb content: Lack a zone of central pallor.
c. sickle cell anemia

Degmatocyte:
a. Define:
b. Describe or Draw cell shape:
c. Medical condition associated with:

a. bite/ helmet cell, Caused by spleen "pitting" of the Heinz body, The cell body is denatured hemoglobin due to oxidative injury.
b. an rbc that has a bite mark, seen in wright stain, heinz are seen in supervita;
c. G6PD deficiency, Drug induced hemolysis

Echinocytes:
a. Define:
b. Describe or Draw cell shape:
c. Medical condition associated with:

a. burr cells, Regularly contracted cells with short, evenly space spikey projections and preserved central pallor.
b. spikey, round cells, nicely spikey
c. Uremia Secondary ATP deficiency, May be associated with altered membrane lipids, Often artifact

Acanthocytes:
a. Define:
b. Describe or Draw cell shape:
c. Medical condition associated with:

a. Defect caused by the increased ratio of cholesterol to phospholipid resulting in an increased surface area, lecithin content is decreased
b. ugly spikey appearance, Irregularly spaced spiny projections on the surface of the RBC. The ends of the projections may be round and fat, maybe a slight loss of central pallor.
c. hemolytic anemia, Alcoholic cirrhosis, Vitamin E deficiency, Post-splenectomy, Severe liver disease, Pyruvate kinase (PK) deficiency, Congenital abetalipoproteinemia

Stomatocytes:
a. Define:
b. Describe or Draw cell shape:
c. Medical condition associated with:

a. Caused by an increased permeability to sodium.
b. bowl-shaped cell with a slit-like area of central pallor. Looks like a screw head for a flathead screwdriver.
c. Acute alcoholism, Hereditary Stomatocytosis, Liver disease, Cirrhosis, Hemolytic anemia