ABC of c.b.c.

1. ABCs of CBC Dr.abdulfattah alshenawi MBBch,Msc,Mrcs (Ireland) Cons,general surgery(M.G.H)

2. objectives Be able to interpret (CBC) reports Recognize common blood disorders Know when to request hematology consultation

3. Remember!

4. Why do we need CBC? Screening? Diagnosing clinical situations. Monitoring disease& effect of treatment Prior to major procedure.

5. Blood components 57% Plasma 1% Buffy coat – WBC 42% RBCS

6. From where bl.cells ? All Blood Cells made in bone marrow. Bone Marrow is the spongy centers of bones sometimes seen in cuts of meat Stem cells are young cells They get “drafted” as RBCs, WBCs or platelets depending on the body’s needs

7. Look for what?

8. Cbc REPORT

9. Results of lab.tests May be affected by Activity Diet Stress Geography medications Time of the day

10. Concept of normal

11. Ref.range

12. PANIC VALUE

13. erythrocytes

14. WBCS DIFF.

15. 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%) RBC S. 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

16. HCT

17. reticulocyte

18. 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 deficiency high RDW + mac.anaemia vit B12&folate def. high RDW + norm.anaemia hge

19. Anaemia ( pathophysiolgy )

20. Proceed to interpretation Is the pt. anaemic ? Low HB = anaemia Look to MCV Normal = normocytic anaemia ? Acute hge = normal Hct explore for the site by HX&PE( shock,revealed or concealed hge ) Haemolysis = high retic ., ( high LDH,low haptoglobin ,& indirect hyperbilirubinaemia,jaundice ) Acute haemolysis , incompatible blood trans. Chronic haemolysis ( Hbpathy,enzymopathy , membranopathy )

21. haemolysis Haemoglobinuria is differentiating between IV&EV haemolysis

22. HB A B A B A A DELTA DELTA A A GAMMA GAMMA HBA A2B2 HBA2 A2D2 HB F A2 G2 Normal variant of HB

23. QUALITATIVE Vs quantitative HBS Def.B Subunit Sickle cell anaemia B, thalass Dec. B chain A.Thalass Dec,A chain Abnormal HB

24. HEREDITARY SPHEROCYTOSIS

25. membranopathies RBCS SHAPE

26. 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

27. Microcytic anaemia Thalasemia I.D.A S.A A.C.D

28. Microcytic anaemia THINK OF DESTURBED HB SUBSTRATES.

29. acd

30. Microcytic anaemia

31. MICROCYTIC ANAEMIA CHECK RBCs thalassemia ACD,SA,IDA S.ferritin Low in IDA High in SA,ACD

32. WHAT IF? High MCV= macrocytic anemia Think of neutritional deficiency Vit B12 Folic acid Do what???????

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

34. Macrocytic anaemia 2)MEGALOPLASTIC 85% pernicious anaemia .(+ ve AB for IF) Macroovalocyte & hypersegm.neutrophil

35. Rule out medic Check vit B12&FOLIC DEC.folate Norm.B12 CONSIDER folate def. Dec.B12 Norm folate Check MMA Increase MMA Confirm def. Both normal Consider alcohol.liver,med hypothyroidism

36. MCV# Microcytic MCV Normocytic Macrocytic I ron Deficiency IDA T halassemias H emoglobinopathies S ideroblastic Anemia Hemolysis Hemorhage Vit B12 Folic acid Alcohol liver dis. drugs

37. POLYCYTHEMIA

38. POLYCYTHEMIA VERA

39. COMPLICATIONS OF POLYCYTH.

40. Cbc REPORT

41. Cbc REPORT

42. Cbc REPORT

43. Cbc REPORT

44. WBCS

45. WBCs Different types Different life span Different functions Different sizes

46. Norms of leukocytes TLC 4-11000/ cmm DLC neutrophil (60%) lymphocyte(30%) eosinophil (6%) monocyte (3%) basophil (1%)

47. wbcS DISORDERS PROLIFERATIVE OR LEUKOPENIA PROLIFERATIVE MAY BE REACTIVE OR NEOPLASTIC DIFFERENTIATION BENIGN FROM MALIGNANT DISORDERS IS OF UTMOST IMPORTANCE.

48. definitions Leukocytosis increase WBCs.>11000 Leukopenia decrease WBCs.<4000 Granulocytosis neutrophilia Granulocytopenia neutropenia <2000/ cmm Agranulocytosis neutropenia <500/ cmm

49. Evaluation of TLC&DLC Leukocytosis ( neoplastic & prolifrative ) Identify infection,inflammation,&tissue damage More than100000/ cmm . seen in leukaemia . Stress & steroids are reversible soon

50. 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 .)

51. NEUTROPHILIA Red flags person particularly unwell severity rate of change of neutrophilia presence of left shift

52. Eosinophilia . Elevated in parasitic infestations& allergy. Intestinal parasite,and toxoplasmosis. Asthma &hay fever.

53. Basophilia . Most uncommon. Seen in systemic hypersensitivity. Thorough allergy history should be obtained before any surgical procedures .

54. Monocytosis . Late in acute infections Chronic infections as TB&SBE. Hodgkin,s lymphoma,fungal Monocytopenia ( aplastic anaemia,glucocorticoid ,&hairy cell leuk ).

55. Lymphocytosis . Origin& maturation Types . Acute viral infections CMV,INF.MONONUCLEOSIS,MMR EARLY H.I.V CLL. Lymphopenia in HIV& AIDS.(CD4 count <200)

56. 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.

57. 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

58. 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 .

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

60. 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 bleeding 20 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

61. 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

62. 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

63. 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)

64. 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)

65. Pseudothrombocytopenia If blood sample is inadequately anticoagulated , platelet clumps can be counted as WBC’s 0.1% of patients have EDTA dependent agglutinins

66. Decreased production Viral infections Direct megakaryocyte damage-HIV Post CT,RT Acquired bone marrow hypoplasia - Fanconi anemia. alcohol toxicity B12 or folate deficiency

67. 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

68. y PS.PENIA TRUE.PENIA Giant plt Isolated TP ITP HIT DIC Neutrophil lymphocyt Consider infection Blast cells Nucleated RBCS 1ry BM DISORDER schistocyte TTP/HUS/DIC THROMBOCYTOPENIA Hereditary thrombocyt PBS PLT clumbing

69. Cbc in acute leukaemia AML Anaemia Leukocytosis Thrombocytopenia >20% blast in PBS >80% blast in BMA PUO+splenomegally Auer rodes ALL Anaemia Leukocytosis Throbocytopenia >20% blast in PBS >80% blast in BMA PUO,LN swelling

70. Cbc in ch.leukaemia CML Anaemia Leukocytosis+lt.shift Lymphocytosis Thrombocytopenia Basophilia splenomegally Philadelphia ch . CLL Anaemia Leukocytosis+lt shift Lymphocytosis Thrombocytosis Basophilia Splenomegally B cell CD19,,CD5 flow cytometry

71. Quiz 1?

72. quiz 2 ?

73. Quiz 3?

74. The End