Laboratory Assessment

of Hematology Disorder

Dept. of Clinical Pathology

Medical School University of Sriwijaya

Reference
Editors: Fischbach, Frances Talaska
Title: Manual of Laboratory & Diagnostic Tests, 7th Edition
Copyright 2004 Lippincott Williams & Wilkin
Blood Studies; Hematology and Coagulation

Kemas Yakub R, dr, SpPK

OVERVIEW OF BASIC BLOOD

HEMATOLOGY AND
COAGULATION TESTS

Kemas Yakub R, dr, SpPK

Composition of Blood
The average person circulates about 5 L of blood
(1/13 of body weight), of which 3 L is plasma and
2 L is cells.
Plasma fluid derives from the intestines and
lymphatic systems and provides a vehicle for cell
movement.
Blood cells are classified as white cells
(leukocytes), red cells (erythrocytes), and
platelets (thrombocytes). White cells are further
categorized as granulocytes, lymphocytes,
monocytes, eosinophils, and basophils
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 Before birth, hematopoiesis occurs in the

liver.
In midfetal life, the spleen and lymph
nodes play a minor role in cell production.
Shortly after birth, hematopoiesis in the
liver ceases, and the bone marrow is the
only site of production of erythrocytes,
granulocytes, and platelets.
B lymphocytes are produced in the marrow
and in the secondary lymphoid organs; T
lymphocytes are produced in the thymus.
Kemas Yakub R, dr, SpPK

Blood Tests
Blood and bone marrow examinations constitute
the major means of determining certain blood
disorders (anemias, leukemia and porphyrias
disorders, abnormal bleeding and clotting),
inflammation, infection and inherited disorders of
red blood cells, white blood cells, and platelets.
Specimens are obtained through capillary skin
punctures (finger, toe, heel), dried blood
samples, arterial or venous sampling, or bone
marrow aspiration. Specimens may be tested by
automated or manual hematology
instrumentation and evaluation.
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CAPILLARY BLOOD COLLECTION

SITES

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THE CORRECT DIRECTION OF

CAPILLARY PUNCTURE

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THE PROPER POSITION FOR

PATIENTS HANDS DURING
CAPILLARY PUNCTURE

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BLOOD SPECIMEN COLLECTION

PROCEDURES
Proper specimen collection presumes correct technique
and accurate timing when necessary. Most hematology
tests use EDTA as an anticoagulant.
Tubes with anticoagulants should be gently but
completely inverted end over end 7 to 10 times after
collection. This action ensures complete mixing of
anticoagulants with blood to prevent clot formation.
Even slightly clotted blood invalidates the test, and the
sample must be redrawn.
For plasma coagulator studies, such as prothrombin time
(PT) and partial thromboplastin time (PTT), the tube
must be allowed to fill to its capacity or an improper
blood-to-anticoagulant ratio will invalidate coagulator
results. Invert 7 to 10 times to prevent clotting.
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Take action to prevent these venipuncture errors:

Pretest errors

Improper patient identification

Failure to check patient compliance with dietary restrictions
Failure to calm patient before blood collection
Use of wrong equipment and supplies
Inappropriate method of blood collection

Procedure errors

Failure to dry site completely after cleansing with alcohol

Inserting needle with bevel side down
Using too small a needle, causing hemolysis of specimen
Venipuncture in unacceptable area (eg, above an intravenous [IV] line)
Prolonged tourniquet application
Wrong order of tube draw
Failure to mix blood immediately that is collected in additive-containing tubes
Pulling back on syringe plunger too forcefully
Failure to release tourniquet before needle withdrawal

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 Posttest errors
Failure to apply pressure immediately to
venipuncture site
Vigorous shaking of anticoagulated blood
specimens
Forcing blood through a syringe needle into tube
Mislabeling of tubes
Failure to label specimens with infectious disease
precautions as required
Failure to put date, time, and initials on requisition
Slow transport of specimens to laboratory
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Bone Marrow Aspiration

Bone marrow is located within cancellous bone and long bone

cavities. It consists of a pattern of vessels and nerves, differentiated
and undifferentiated hematopoietic cells, reticuloendothelial cells,
and fatty tissue. All of these are encased by endosteum, the
membrane lining the bone marrow cavity. After proliferation and
maturation have occurred in the marrow, blood cells gain entrance
to the blood through or between the endothelial cells of the sinus
wall.
A bone marrow specimen is obtained through aspiration or biopsy or
needle biopsy aspiration. A bone marrow examination is important in
the evaluation of a number of hematologic disorders and infectious
diseases. The presence or suspicion of a blood disorder is not
always an indication for bone marrow studies. A decision to employ
this procedure is made on an individual basis.

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BASIC BLOOD TESTS

Hemogram
A hemogram consists of a white blood cell
count (WBC), red blood cell count (RBC),
hemoglobin (Hb), hematocrit (Hct), red
blood cell indices, and a platelet count. A
complete blood count (CBC) consists of a
hemogram plus a differential WBC.

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Complete Blood Count (CBC)

The CBC is a basic screening test and is
one of the most frequently ordered
laboratory procedures. The findings in the
CBC give valuable diagnostic information
about the hematologic and other body
systems, prognosis, response to
treatment, and recovery. The CBC consists
of a series of tests that determine number,
variety, percentage, concentrations, and
quality of blood cells:
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White blood cell count (WBC): leukocytes fight infection

Differential white blood cell count (Diff): specific patterns of WBC
Red blood cell count (RBC): red blood cells carry O2 from lungs to
blood tissues and CO2 from tissue to lungs
Hematocrit (Hct): measures RBC mass
Hemoglobin (Hb): main component of RBCs and transports O2 and
CO2
Red blood cell indices: calculated values of size and Hb content of
RBCs; important in anemia evaluations
Mean corpuscular volume (MCV)
Mean corpuscular hemoglobin concentration (MCHC)
Mean corpuscular hemoglobin (MCH)
Stained red cell examination (film or peripheral blood smear)
Platelet count (often included in CBC): thrombocytes are necessary
for clotting and control of bleeding
Red blood cell distribution width (RDW): indicates degree variability
and abnormal cell size.
Mean platelet volume (MPV): index of platelet production
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White Blood Cell Count (WBC;

Leukocyte Count)
White blood cells (or leukocytes) are divided into two
main groups: granulocytes and agranulocytes.
The granulocytes receive their name from the distinctive
granules that are present in the cytoplasm of neutrophils,
basophils, and eosinophils. However, each of these cells
also contains a multilobed nucleus, which accounts for
their also being called polymorphonuclear leukocytes. In
laboratory terminology, they are often called PMNs.
The nongranulocytes, which consist of the lymphocytes
and monocytes, do not contain distinctive granules and
have nonlobular nuclei that are not necessarily spherical.
The term mononuclear leukocytes is applied to these
cells.
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 Leukocytosis: WBC >11,000/mm3 or

>11.0 103/mm3 (or >11 109/L)
It is usually caused by an increase of only one
type of leukocyte, and it is given the name of
the type of cell that shows the main increase:

Neutrophilic leukocytosis or neutrophilia

Lymphocytic leukocytosis or lymphocytosis
Monocytic leukocytosis or monocytosis
Basophilic leukocytosis or basophilia
Eosinophilic leukocytosis or eosinophilia
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 In certain diseases (eg, measles, pertussis, sepsis), the increase

of leukocytes is so great that the blood picture suggests
leukemia. Leukocytosis of a temporary nature (leukemoid
reaction) must be distinguished from leukemia. In leukemia, the
leukocytosis is permanent and progressive.
Leukocytosis occurs in acute infections, in which the degree of
increase of leukocytes depends on severity of the infection,
patient's resistance, patient's age, and marrow efficiency and
reserve.
Other causes of leukocytosis include the following:

Leukemia, myeloproliferative disorders

Trauma or tissue injury (eg, surgery)
Malignant neoplasms, especially bronchogenic carcinoma
Toxins, uremia, coma, eclampsia, thyroid storm
Drugs, especially ether, chloroform, quinine, epinephrine (Adrenalin),
colony-stimulating factors
Acute hemolysis
Hemorrhage (acute)
After splenectomy
Polycythemia vera
Tissue necrosis
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 Leukopenia: WBC <4000/mm3 or <4.0 103/mm3 or

<4.0 cells 109/L occurs during and following:
Viral infections, some bacterial infections, overwhelming bacterial
infections
Hypersplenism
Bone marrow depression caused by heavy-metal intoxication,
ionizing radiation, drugs:

Antimetabolites
Barbiturates
Benzene
Antibiotics
Antihistamines
Anticonvulsives
Antithyroid drugs
Arsenicals
Cancer chemotherapy (causes a decrease in leukocytes; leukocyte
count is used as a link to disease)
Cardiovascular drugs
Diuretics
Analgesics and antiinflammatory drugs
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 Differential White Blood Cell Count (Diff;

Differential Leukocyte Count)
The total count of circulating white blood
cells is differentiated according to the five
types of leukocytes, each of which
performs a specific function.

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Cell

These Cells Function to Combat

Neutrophils

Pyogenic infections (bacterial)

Eosinophils

Allergic disorders and parasitic infestations

Basophils

Parasitic infections, some allergic disorders

Lymphocytes Viral infections (measles, rubella,

chickenpox, infectious mononucleosis)
Monocytes

Severe infections, by phagocytosis

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TESTS OF RED BLOOD CELLS

Many tests look at the red blood cells: their number and
size, amount of Hb, rate of production, and percent
composition of the blood. The red blood cell count
(RBC), hematocrit (Hct), and hemoglobin (Hb) are
closely related but different ways to look at the adequacy
of erythrocyte production. The same conditions cause an
increase (or decrease) in each of these indicators.
The RBC test, an important measurement in the
evaluation of anemia or polycythemia, determines the
total number of erythrocytes in a microliter (cubic
millimeter) of blood.

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Decreased RBC values occur in:

Anemia, a condition in which there is a reduction in
the number of circulating erythrocytes, the amount of
Hb, or the volume of packed cells (Hct). Anemia is
associated with cell destruction, blood loss, or dietary
insufficiency of iron or of certain vitamins that are
essential in the production of RBCs.
Disorders such as:

Hodgkin's disease and other lymphomas

Multiple myeloma, myeloproliferative disorders, leukemia
Acute and chronic hemorrhage
Lupus erythematosus
Addison's disease
Rheumatic fever
Subacute endocarditis, chronic infection
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Erythrocytosis (increased RBC) occurs in:

Primary erythrocytosis
Polycythemia vera (myeloproliferative disorder)
Erythremic erythrocytosis (increased RBC production in bone
marrow)
Secondary erythrocytosis
Renal disease
Extrarenal tumors
High altitude
Pulmonary disease
Cardiovascular disease
Alveolar hypoventilation
Hemoglobinopathy
Tobacco/carboxyhemoglobin
Relative erythrocytosis (decrease in plasma volume)
Dehydration (vomiting, diarrhea)
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 Hematocrit (Hct); Packed Cell Volume

(PCV)
The Hct test is part of the CBC. This test
indirectly measures the RBC mass. The
results are expressed as the percentage
by volume of packed RBCs in whole blood
(PCV). It is an important measurement in
the determination of anemia or
polycythemia.
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 Decreased Hct values are an indicator of anemia, a

condition in which there is a reduction in the PVC. An Hct
<30% (<0.30) means that the patient is moderately to
severely anemic. Decreased values also occur in the
following conditions:
Leukemias, lymphomas, Hodgkin's disease, myeloproliferative
disorders
Adrenal insufficiency
Chronic disease
Acute and chronic blood loss
Hemolytic reaction: this condition may be found in transfusion of
incompatible blood or as a reaction to chemicals or drugs,
infectious agents, or physical agents (eg, severe burns, prosthetic
heart valves).
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 Increased Hct values occur in:

Erythrocytosis
Polycythemia vera
Shock, when hemoconcentration rises
considerably

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Hemoglobin
Hb, the main component of erythrocytes, serves as the
vehicle for the transportation of oxygen and carbon
dioxide. It is composed of amino acids that form a single
protein called globin, and a compound called heme,
which contains iron atoms and the red pigment
porphyrin. It is the iron pigment that combines readily
with oxygen and gives blood its characteristic red color.
Each gram of Hb can carry 1.34 mL of oxygen per 100
mL of blood. The oxygen-combining capacity of the
blood is directly proportional to the Hb concentration
rather than to the RBC because some RBCs contain
more Hb than others. This is why Hb determinations are
important in the evaluation of anemia.
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 Decreased Hb levels are found in anemia states (a

condition in which there is a reduction of Hb, Hct, and/or
RBC values). The Hb must be evaluated along with the
RBC and Hct.
Iron deficiency, thalassemia, pernicious anemia,
hemoglobinopathies
Liver disease, hypothyroidism
Hemorrhage (chronic or acute)
Hemolytic anemia caused by:

Transfusions of incompatible blood

Reactions to chemicals or drugs
Reactions to infectious agents
Reactions to physical agents (eg, severe burns, artificial heart valves)
Various systemic diseases:

Hodgkin's disease
Leukemia
Lymphoma
SLE
Carcinomatosis
Sarcoidosis
Renal cortical necrosis
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 Increased Hb levels are found in:

Polycythemia vera
Congestive heart failure
Chronic obstructive pulmonary disease (COPD)

Variation in Hb levels:
Occurs after transfusions, hemorrhages, burns. (Hb
and Hct are both high during and immediately after
hemorrhage.)
The Hb and Hct provide valuable information in an
emergency situation if they are interpreted not in an
isolated fashion but in conjunction with other pertinent
laboratory data.
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Clinical Implications of Anemia:

Decreased RBC, Hct, and/or Hb
Anemia is the term used to describe a
condition in which there is a reduction in
the number of circulating RBCs, the
amount of Hb, and/or volume of packed
cells (Hct). A pathophysiologic
classification of anemias based on their
underlying mechanisms follows.
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 Hypoproliferative anemias (inadequate

production of RBCs):

Marrow aplasias
Myelophthisic anemia
Anemia with blood dyscrasias
Anemia of chronic disease
Anemia with organ failure

Maturation defect anemias:

Cytoplasmic: hypochromic anemias
Nuclear: megaloblastic anemias
Combined: myelodysplastic syndromes
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 Hyperproliferative anemias (decreased Hb or Hct despite

an increased production of RBCs):
Hemorrhagic: acute blood loss
Hemolytic: a premature, accelerated destruction of RBCs

Immune hemolysis
Primary membrane
Hemoglobinopathies
Toxic hemolysis (physical-chemical)
Traumatic or microangiopathic hemolysis
Hypersplenism
Enzymopathies
Parasitic infections

Dilutional anemias:
Pregnancy
Splenomegaly
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 The panic Hb value is <5.0 g/dL (<50 g/L), a

condition that leads to heart failure and death. A
value >20 g/dL (>200 g/L) leads to clogging of
the capillaries as a result of hemoconcentration.
Red Blood Cell Indices
The red cell indices define the size and Hb
content of the RBC and consist of the mean
corpuscular volume (MCV), the mean
corpuscular hemoglobin concentration (MCHC),
and the mean corpuscular hemoglobin (MCH)
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Mean Corpuscular Volume (MCV)

Individual cell size is the best index for
classifying anemias. This index expresses the
volume occupied by a single erythrocyte and is a
measure in cubic micrometers (femtoliters, or fL)
of the mean volume. The MCV indicates whether
the red blood cell size appears normal
(normocytic), smaller than normal (<82 m3,
microcytic), or larger than normal (>100 m3,
macrocytic).
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Mean Corpuscular Hemoglobin

Concentration (MCHC)
The MCHC measures the average
concentration of Hb in the RBCs. The
MCHC is most valuable in monitoring
therapy for anemia because the two most
accurate hematologic determinations (Hb
and Hct) are used in its calculation.
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Mean Corpuscular Hemoglobin (MCH)

The MCH is a measure of the average weight of
Hb per RBC. This index is of value in diagnosing
severely anemic patients.
Red Cell Size Distribution Width (RDW)
This automated method of measurement is
helpful in the investigation of some hematologic
disorders and in monitoring response to therapy.
The RDW is essentially an indication of the
degree of anisocytosis (abnormal variation in
size of RBCs). Normal RBCs have a slight
degree of variation.
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Stained Red Cell Examination

(Film; Stained Erythrocyte
Examination)
The stained film examination determines
variations and abnormalities in erythrocyte size,
shape, structure, Hb content, and staining
properties. It is useful in diagnosing blood
disorders such as anemia, thalassemia, and
other hemoglobinopathies. This examination
also serves as a guide to therapy and as an
indicator of harmful effects of chemotherapy and
radiation therapy. The leukocytes are also
examined at this time.
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