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The complete blood count (CBC) with differential is one of the most
common laboratory tests performed today. It gives information
about the production of all blood cells and identifies the patients
oxygen-carrying capacity through the evaluation of red blood cell
(RBC) indices, hemoglobin, and hematocrit. It also provides information about the immune system through the evaluation of the white
blood cell (WBC) count with differential. These tests are helpful in
diagnosing anemia, certain cancers, infection, acute hemorrhagic
states, allergies, and immunodeficiencies as well as monitoring for
side effects of certain drugs that cause blood dyscrasias. Nurses in the
perianesthesia arena are frequently challenged to obtain and evaluate all or parts of the CBC as a part of the patients preoperative,
intraoperative, and postoperative assessments. An enhanced understanding of this laboratory test is essential to providing quality care.
2003 by American Society of PeriAnesthesia Nurses.
ObjectivesBased on the content of this article, the reader should be able to (1) discuss the
physiology of blood cell production; (2) describe the usefulness of the complete blood count (CBC);
(3) identify and differentiate the roles of the different types of leukocytes; (4) describe the characteristics of red blood cell (RBC) structure and function; (5) discuss the indications for CBC as part of
the perianesthesia evaluation; and (6) explore the nursing indications related to CBC findings in the
perianesthesia setting.
4,500 to 11,000/L
See Table 7
4.0 to 6.2 million/L
35% to 47%
39% to 50%
37% to 51%
12 to 16 g/dL
14 to 18 g/dL
82 to 93 m3
26 to 34 pg
31% to 38%
150,000 to 400,000 L
Screening
Screening usually refers to testing patients
who are asymptomatic and have no physical
signs of disease. However, symptoms or physical signs may be very insensitive indicators of
some diseases. In the perianesthesia setting, the
use of the CBC as a screening tool constantly
undergoes revision. Factors such as the prevalence of disease in a population, the medical
and financial impact of missing a problem, the
cost per problem found, financial reimburse-
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Indications
Preoperative evaluation should include a history, a physical examination, laboratory tests,
and an assessment of surgical risk to identify
coexisting diseases and complicating conditions. To decrease the risk of morbidity and
mortality in the perianesthesia setting, the CBC
is used to assist with the identification of patients who are at risk for complications of inadequate tissue perfusion during the procedure
and those with a possible infectious or inflammatory process.3,4
General indications for a CBC that are considered medically reasonable and are accepted by
Medicare are as follows:
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Table 2. Signs, Symptoms, and Conditions That May Warrant a CBC or Parts of a CBC
Hemogram
Hemogram
Hemogram
Fever
Chills
Ruddy skin
Conjunctival redness
Cough
Wheezing
Cyanosis
Clubbing of the fingers
Orthopnea
Heart murmur
Headache
Memory changes
Sleep apnea
Weakness
Pruritus
Dizziness
Excessive sweating
Massive obesity
Gastrointestinal bleeding
Paresthesias
Myocardial infarction
Stroke
Thromboembolism
Hepatomegaly
Splenomegaly
COPD
Diastolic hypertension
Congenital heart disease
Transient ischemic attack
Visual symptoms
Gastrointestinal bleed
Genitourinary tract bleed
Bilateral epistaxis
Thrombosis
Ecchymosis
Purpura
Jaundice
Petechiae
Fever
Heparin therapy
Suspected DIC
Shock
Preeclampsia
Massive transfusion
Recent platelet transfusion
Cardiopulmonary bypass
Renal diseases
Hypersplenism
Neurologic abnormalities
Viral or other infection
Thrombosis
Exposure to toxic agents
Excessive alcohol ingestion
Autoimmunue disorders
(SLE, RA)
Hepatomegaly
Splenomegaly
Lymphadenopathy
Pallor
Weakness
Fatigue
Weight loss
Bleeding
Acute or suspected blood loss
from injury
Hematuria
Hematemesis
Hematochezia
Positive fecal occult
Neuropathy
Malnutrition
Tachycardia
Known malignancy
Systolic heart murmur
Congestive heart failure
Dyspnea
Angina
Postural dizziness
Syncope
Nailbed deformities
Known malignancy
Jaundice
Hepatomegaly
Splenomegaly
Lymphadenopathy
Ulcers of the lower extremities
Fever
Chills
Sweats
Shock
Fatigue
Malaise
Tachycardia
Tachypnea
Heart murmur
Seizures
Altered consciousness
Pain such as headache
Abdominal pain
Arthralgia
Odynophagia
Dysuria
Redness/swelling of skin soft
tissue or joint
Ulcers of skin or mucous
membrane
Gangrene
Bleeding
Thrombosis
Pulmonary infiltrate
Jaundice
Diarrhea
Vomiting
Opportunistic infections as
oral candidiasis
Hepatomegaly
Splenomegaly
Lymphadenopathy
Abbreviations: COPD, chronic obstructive pulmonary disease; DIC, disseminated intravascular coagulation; SLE, systemic lupus erythematosus; RA,
rheumatoid arthritis.
Data from Centers for Medicare and Medicaid Services (CMS). Available at www.cms.hhs.gov/ncd/searchdisplay.asp?NSD_ID61&NCD_vrsn_num1.
pacity of blood before surgery for patients who do not have the previously
listed signs, symptoms, or conditions
(Table 2). The H&H may be helpful in
the intraoperative and postoperative
phase of care to assess and track for
blood loss but can be misleading because
of the intercompartmental fluid shifts
that occur during surgery and because of
the dilutional effects of crystalloid therapy.
Specific perianesthesia indications for the CBC
also take into account the level of surgical com-
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Description
Examples
1
2
6
E
Blood
The average adult has approximately 5.5 L of
blood, consisting of plasma and cells. Plasma
makes up 55% of the blood components and
consists of proteins, water, and some waste
products. Cells, of which there are 3 main
types, make up the other 45%. They consist of
(1) WBCs (leukocytes), of which there are several subtypes; (2) RBCs (erythrocytes); and (3)
platelets (thrombocytes).
All blood cells are produced in the bone marrow from a mother cell called the pluripotential
(multipotential) stem cell (PSC). This PSC undergoes stages of differentiation until it becomes committed to either the erythrocyte,
thrombocyte, or one of the leukocyte subtypes
(Fig 1). Under normal conditions, only mature
blood cells should be found circulating in the
blood. Alterations in the production and function of these blood cells provide information
about the patients diagnosis, prognosis, re-
Fig 1.
101
102
tissue that have been infected by microorganisms, as well as cancer cells. Cell-mediated immunity provides primary defense against viruses, fungi, slow-growing bacteria, and tumors.
Humoral immunity or antibody-mediated immunity involves the production of antibodies
by B cells and mainly occurs in body fluid such
as plasma and lymph. Humoral immunity provides primary defense against bacteria. Cell-mediated immunity is initiated frequently first, but
both cell-mediated and humoral immunity can
be initiated simultaneously. Both types of immunity require specific types of WBCs to be effective.
Fig 2.
103
104
Kupffer cells
Alveolar macrophage
Histocytes
Pleural and peritoneal macrophages
Microglial cells
Osteoclasts
Mesangial
Langerhans
Dendritic cells
Tissue
Liver
Lung
Connective tissue
Serous cavities
Nervous system
Bones
Kidneys
Skin
Lymphoid tissue
105
Absolute (L)
Differential (%)
Total WBC
Granulocytes
Neutrophils
Segmented
Bands
Eosinophils
Basophils
Nongranulocytes
Monocytes
Lymphocytes (Immunocytes)
T cells
B cells
Natural killer
4,500-11,000
100
3,000-7,000
2,800-5,600
150-600
50-400
25-100
60-70
54-68
3-5
1-5
0-0.75
100-800
1,000-4,000
800-3,200
100-600
50-400
3-7
25-33
80*
10-15*
5-10*
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Neutrophilia is an increase in the total neutrophil count (including both segs and bands).
Because neutrophils account for greater than
96% of all granulocytes, neutrophilia may also
be referred to as granulocytosis. It is the most
common cause of elevated WBC count.
Neutrophilia is most commonly caused by an
acute bacterial infection. Neutrophil counts will
rise 4 to 6 hours after an invasion by microorganisms. If findings do not suggest infection, a
myeloproliferative disorder may be the cause.
Myeloproliferative disorders include polycythemia vera and chronic myelocytic leukemia,
which increases stem cell proliferation in the
bone marrow. Elevations in neutrophil counts
are also associated with obesity and cigarette
smoking. Additionally, neutrophil counts can
increase after the stress of surgery, but in this
case, counts will quickly return to normal if no
infection is present.12
An elevation in segmented neutrophils is considered a shift to the right. During tissue
breakdown from injuries such as burns, arthritis, myocardial infarction, hemorrhage, or electric shock, neutrophils are called in to clean up
the damaged or dead cells. In this case, reserve
mature neutrophils are called in, thereby increasing the neutrophil count without calling in
the immature cells. A severely elevated neutrophil count will be seen in certain pathologic
conditions causing the neutrophils to become
hypermature. Hypermature segmented neutrophils are those in which nuclear segmentation is
impaired, and there is an increased number of
segments (5). This is seen in liver disease,
Downs syndrome, and megaloblastic and pernicious anemia.
An elevation in bands is referred to as a shift to
the left, which means that there is an increased
number of immature neutrophils released from
Eosinophilia identifies an increase in the eosinophil count. This count has been found to
increase with parasitic infections such as toxoplasmosis and with infections by gastrointestinal parasites. Elevations have also been noted
with bronchoallergic reactions such as asthma,
allergic rhinitis, and hay fever. Eosinophilia has
also been noted with skin rashes.
Basophilia
107
Reductions in eosinophil (eosinopenia) and basophil (basopenia) counts are uncommon because so few of these cells normally circulate in
the blood. Monocytopenia is a rare occurrence
but has been seen with glucocorticoid therapy,
hairy-cell leukemia, and aplastic anemia. Lymphopenia, a decreased lymphocyte count, occurs normally as a person ages. Lymphopenia is
most significant with HIV and acquired immunodeficiency syndrome (AIDS). A CD4 count
(remember the helper T lymphocyte has the
CD4 marker on its surface) of less than 200 is
one indicator of conversion from HIV to AIDS.
Nursing Implications
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109
General surgery
Minor procedure without additional risk factors
in patients less than 40 years of age
Minor procedure with additional risk factors in
patients less than 40 years of age
Minor procedure in patients 40 to 60 years of age
without additional risk factors
Major surgery in patients without additional risk
factors 40 years of age
Nonmajor surgery with additional risk factors in
patients 60 yr
Major surgery in patients 40 yrs or with
additional risk factors
Major surgery in patients 40 with multiple risk
factors
Gynecologic surgery
Major surgery for benign disease without
additional risk factors
Extensive surgery for malignancy
Urologic surgery
Transurethral surgery or other low-risk procedure
Major open urologic procedure
Highest risk patients
Orthopedic surgery
Elective total hip replacement
Trauma
Acute SCI
Medical conditions
Acute myocardial infarction
Ischemic stroke
General medical conditions with risk factors
Recommended Prophylaxis
Low risk
Early ambulation
Moderate risk
LDUH every 12 hours starting 1 to 2 hours before surgery
LMWH first dose generally before surgery
ES or IPC device to start immediately before procedure and continue until fully
ambulatory
High risk
LDUH every 8 hours, LMWH, or IPC device
NOTE. Risk factors include previous VTE, increasing age, major surgery, cancer, obesity, major trauma, lower extremity or hip fracture, pregnancy,
history of myocardial infarction, stroke, heart failure, hormone replacement therapy, prolonged immobilization, burns, paralysis, hypercoagulable
states, indwelling femoral vein catheter, inflammatory bowel disease.
Abbreviations: LDUH, low-dose unfractioned heparin; LMWH, low molecular weight heparin; ES, elastic stocking; IPC, intermittent pneumatic
compression; IFC, inferior vena cava; DVT, deep vein thrombosis; SCI, spinal cord injury.
Data from Geerts WH, Heit JA, Clagett GP, et al: Prevention of venous thromboembolism, Sixth ACCP Consensus Conference on Antithrombotic
Therapy. Chest 119:132s-175s, 2001, and Hirsh J: Managing venous thromboembolism: Methodology for achieving positive outcomes. CME-Today
(Cardiopulmonary and Critical Care) 1:11-15, 2002.
110
As previously mentioned, Hgbs primary function is to carry oxygen to the cells and remove
carbon dioxide from the cells. Hgb is a complex
protein made up of heme and globin. It is
produced in the immature RBC. Synthesis stops
once the cell matures in circulation. There are
approximately 300 million molecules of Hgb in
one RBC. Hgb is measured in grams per deciliter. See Table 10 for normal values.
Adult male
Adult female
Conventional Units
SI Units
13.5-18 g/dL
12-16 g/dL
135-180 g/L
120-160 g/L
Hct represents the percentage of the total volume of RBCs relative to the total volume of
whole blood in a sample. Hematocrit means
to separate blood. With todays method of
automated cell counting, Hct is calculated
rather than centrifuged. See Table 11 for normal
values. The surgeon and anesthesia provider
must be notified for values of less than 20% or
greater than 60%. Swelling of the RBC secondary to hyperglycemia or hypernatremia may
produce an elevated Hct. Excessively elevated
WBC counts may also alter the Hct.
Adult male
Adult female
Conventional Units
SI Units
4.6-6.2 million/L
4.2-5.4 million/L
4.6-6.2 1012/L
4.2-5.4 1012/L
The RBC count, Hct, and Hgb are closely related. Alterations in one are usually associated
Adult male
Adult female
Conventional Units
SI Units
40%-54%
38%-47%
0.40-0.54
0.38-0.47
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112
Adult
MCV
MCH
MCHC
Conventional Units
SI Units
82-93 m3
26-34 pg
31-38%
82-93 fL
1.61-2.11 fmol
19.2-23.58 mm/L
RBC Indices
113
Platelets (Thrombocytes)
Nursing Implications
114
Summary
It is clear that the needs of patients in the
perianesthesia setting are driven by the context
of their respective surgical treatment plans.
These needs become complex when integrated
with the magnitude of premorbid conditions
and drug profiles that exist for each individual
patient. Knowledge of a patients premorbid
state and medications should heighten the clinicians awareness and analysis of specific CBC
and differential results.
References
1. Chernecky C, Berger BJ (eds): Laboratory Tests and Diagnostic Procedures (ed 3). Philadelphia, PA, Saunders, 2001, pp
372-376
2. Centers for Medicare and Medicaid Services (CMS): National Coverage Determinations for Blood Counts. Available at
www.cms.hhs.gov/ncd/searchdisplay.asp?NCD_ID61&NCD_
vrsn_num1. Accessed December 2002.
3. Goodnough LT, Brecher ME, Katner MH, et al: Transfusion
medicine: Blood transfusion. N Engl J Med 340:438-447, 1999
4. Medicare Part B Model Local Medical Review Policy, Subject: Blood counts. Avera Health Lab News. 4:2-4, 2000. Available
at www.averalabnet.com/newsletters/NewsJanFeb00.htm. Accessed December 2002
5. Cannon CP, McCabe CH, Wilcox RG, et al: Association of
white blood cell count with increased mortality in acute myocardial infarction and unstable angina pectoris. Am J Cardiol
87:636-639, 2001
6. Baylor College of Medicine: Geriatric assessment, medical
assessment, laboratory work-up. Available at www.geri-ed.
com/modules/Asses/assess/medical_assessment.htm. Accessed
December 2002
7. Banasik JL: Inflammation and Immunity, in Copstead LC,
Banasik JL (eds): Pathophysiology Biological and Behavioral Perspectives (ed 2). Philadelphia, PA, Saunders, 2000, pp 184-218
115
Posttest Questions
1. In the process of erythropoiesis, iron is needed for
a. hemoglobin synthesis.
b. DNA synthesis.
c. reproduction.
d. renal excretion.
2. When monitoring a patient who is not bleeding, the nurse would expect to find an increase
in Hct of 3% after a transfusion of one unit of packed RBCs.
a. True
b. False
3. The amount of blood combined with Hgb is a measurement of
a. partial pressure of oxygen (PaO2).
b. arterial-venous oxygen difference.
c. oxyhemoglobin.
d. oxygen saturation (SaO2).
4. In an adult patient with normal Hgb, the nurse will estimate the Hgb to be 10 g/dL if the Hct
was reported to be 30%.
a. True
b. False
5. Secondary physiologic polycythemia is caused by all of the following except
a. congestive heart failure.
b. renal failure.
c. high altitudes.
d. chronic obstructive pulmonary disease.
6. Pernicious anemia is caused by
a. alcoholism.
b. chronic blood loss.
c. vitamin B12 deficiency.
d. iron deficiency.
7. An elevated reticulocyte count would be expected in
a. a recovering trauma patient who lost significant amounts of blood.
b. a patient with a chronic inflammatory disease.
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3.
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a.
b.
c.
d.
a.
b.
c.
d.
a.
b.
c.
d.
8.
13.
4.
a.
b.
5.
9.
a.
b.
10.
14.
a.
b.
c.
d.
15.
a.
b.
c.
d.
a.
b.
c.
d.
a.
b.
Please Print
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Address
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Zip
Social Security
ASPAN Member #
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SA
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