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Ann. rheum. Dis. (1958), 17, 234.

ESTIMATION OF THE ERYTHROCYTE SEDIMENTATION RATE OF CAPILLARY BLOOD
DESCRIPTION OF A NEW METHOD
BY

H. E. D. LLOYD
Bland-Sutton Institute of Pathology, Middlesex Hospital, London

Venous blood is necessary for the estimation of the erythrocyte sedimentation rate (E.S.R.) by the methods of Westergren (1921) and Wintrobe and Landsberg (1935), but venepuncture may occasionally prove difficult or impossible, owing to such factors as inadequate veins, obesity, and flexion deformities. A search was therefore undertaken for a reliable method of estimating the E.S.R. using capillary blood. The consensus of opinion (Nichols, 1942) is that under similar conditions the erythrocyte sedimentation rates of capillary and venous blood are comparable.
Review of Micromethods Many micromethods are to be found in the literature, and unpublished methods undoubtedly exist. Table I summarizes those methods which seem to be the most widely known; details are also given of two unpublished micromethods and of the Westergren macromethod. Westergren (1957) warns against micromethods, and several other writers believe that the narrow tubes used in certain micromethods cause slowing and irregularity of the sedimenting column of cells (Ham and Curtis, 1938). Thygesen (1942) states that occasionally the E.S.R. is accelerated by narrow tubes. The recommended internal diameter has been variously stated as: over 1 5 mm. (Thygesen), over 2 mm. (Ham and Curtis, 1938), over 2-2 mm. (Westergren, 1957), and 2- 5 mm. (MArtensson and Hansen, 1953). Many authors, however, claim reliable results from methods utilizing tubes of an internal diameter of 1 mm. or even less (Table I). In part these discrepancies may be accounted for by the anticoagulant, as MArtensson and Hansen and other workers have shown that diluted blood is less likely to be affected by the bore of the tube than blood to which a solid anticoagulant

has been added. Table I (opposite) shows that five micromethods employ tubes of an internal diameter of 2 mm. or over. It is certain that these methods will distinguish normal from abnormal sedimentation rates, but since a micromethod should not need more than 0 3 ml. blood, it is obvious that the wider the bore of the tube the shorter the column must be. It was considered that the results from any micromethod chosen should be capable of accurate conversion at all rates of sedimentation into the corresponding Westergren values, the Westergren method being probably the commonest venous method in use in Great Britain (Dacie, 1956a) and the most reliable (Lawrence, 1953; Duxbury, 1957; and others). In effect, this means that the sedimenting column used in the micromethod must be of the same length as that used in the Westergren method, if Westergren values in the range of 70130 mm. at 1 hour are to be differentiated; for it is obvious that the maximum possible E.S.R. in mm. at 1 hour will vary directly with the length of the column used. As an example of the undesirability of using a short tube, Nelson and Whyte (1955), using Method 8 (sedimenting column only 38 mm. long), found that "any reading by the micromethod of more than 10 mm. in half an hour or 15 mm. in one hour, may correspond to a Westergren value of anything from 40-140 mm. in one hour". They state that the maximum rate of fall would give a much closer correlation between the methods, but, since multiple readings are inconvenient, it seemed advisable to test the claims of Peters (1945) for the only method (No. 7, Table I) employing a sedimenting column 200 mm. long. Good agreement with the Westergren method is apparent in the values obtained by Peters in thirty patients, though it is not clear from his paper whether he used capillary or venous blood in the smaller tubes.
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Volume of of Blood ting Tube Column Required Method No. at 1 hr (max. J. 40. to 4 vols blood 3-8 per cent.. Na citrate. 1 vol. Na citrate.) 7 Peters .S 1-8 mm.. single was etched on each capillary tube at 200 mm.. 3-10 mm. 1943 2 (max. at hr Blood taken directly 8 Nelson and Whyte 1955 38 0-16 citrate. at 1 hr citrate. . Na 11I Present Method . Smethwick Birmingham. 0-05 0-3 1940 Various dry anticoagulants Saturated Na oxalate to 4 mm.Published by group. so 4 vols blood (max. I vol. Na Crista apparatus (Mesars. Unpub- 2 1-5 100 100 03 02 3-8 per cent. Na citrate. 1 vol. -6 mm.. 1 vol. I vol. at hr~iApparatus obtainable from Messrs Hawks- ley. * Obtainable from Messrs. . and may A be put in Westergren stands. to 7-5 vols blood 5 per cent... . . London Modification of Peters' method. 2013 .. the Westergren mixture) were put up in Westergren tubes and in Veridia microtubes. citrate (i.) mark obtained. Ormond Street. Modification of Cutler's method 5 6 .) 0-3 I Cutler . to 4 vols blood 5 per cent. Peters used tubes 300 in length. at 30 min. Unpublished . 1934 1936 2-5 0-79-1 100 50 64-102 100 0-08 03 3 -8 per cent. throughout the scale of E.) 10 mm. Na citrate. (a) Venous Blood. mark 3 -8 per cent. 1927 Serial readings must be taken Modification of the Linzenmeier -Raunert method. 1945 1-2 2-5 200 0-25 As for standard Westergrenmethod into tube (max. Gt. at 1957 citrate. 1-25 200 0-25 2-15 mm. iModification of Bala10 mm. . at 15 min. sodium Citrate inl the proportion 4 Vols blood to 1 Vol. to 4 vols blood 4-10m . 1 vol.) 25 (mm. at 1 hr Obermer . See also Goldberger (1940). Ltd. were "Veridia"* internal tubes of this length and of 1-25 diameter (tolerance ±0-01 mm.Rs. W.) 10 mm. accordingly mm. at 1 hr ± 001 citrate.com ESTIMATING ERYTHROCYTE SEDIMENTATION RATE OF CAPILLARY BLOOD 235 TABLE I PARTICULARS OF TWELVE METHODS Internal Length of Approx.e.) 50 (m.. so 4 vols blood 3-10 mm. I hr Results using Peters' Method mm. 1938 . Diameter Sedimen. . that Normal Values A nearly horizontal line Comment (mm. Na 35 5mm.bmj.Downloaded from ard. Chance Bros. Na to ~~~~~~~~~~citrate 12 mm. at 30 min chowsky's method 25 mm.bmj. .S. and slowing and irregularity of the sedimenting column of cells did not present problems. The microtubes were no more difficult to read than the macrotubes. of length of column 4 mm. 1933 1 I 50 0-04 amount adhering to walls of tube 5 per cent. Results corrected to correspond to Westergren values 10 Ilished 38 per cent. Authors Date Anticoagulant 3 pe cent. 9 Bodian Matr .com on January 16.01. to 5 vols blood 200 1-6 12Westergren ~~I 1921 2-5 3-8 per cent..-75 samples of venous blood diluted with 3-8 per cent. Na citrate. Analysis of Table II (overleaf) shows that equivalent readings were obtained. Hawksley. 1 vol. London. These tubes have stout walls. at 1 hr Method similar to that used at Hospital for Sick Children.. except in the cases marked with an asterisk. see also 2 Landau . to 4 vols blood atlIhr 0-20 per cent. 1 vol.Y at 1 hr mark Rogatz (1943) 3 4 McSweeney Smith Kato .) 4 mm. Na 9 mm.

I cent. The effect of the addition of the correct quantity of Wintrobe's solid anticoagulant mixture of oxalates (Wintrobe and Landsberg. Capillary 4 vols. 1935) was also determined.. I Vol. internal diameter 1 25 mm. As such a factor would. 112 12 12 12 13 13 13 15 16 18 18 18 19 20 20 22 23 23 27 27 28 29 29 30 30 32 36 2 3 4 S 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 2 5 6 7 8 8 9 9 12 12 13 16 20 28 30 30 32 37 41 48 55 58 2 9 5 11 6 8 9 11 10 12 18 19 14 36 28 29 32 31 clotted 65 79 clotted 2 3 4 S 6 7 8 9 10 ii 12 13 14 15 7 7 13 14 18 20 26 27 34 34 38 40 42 50 55 5 12 15 25 24 19 31 45 32 40 52 49 51 48 69 37 37 40 41 41 48 48 48 49 50 53 54 55 73 74 75 123 57 58 70 78 93 74 72 90 132 Micro =Veridia microtubes. This was therefore adopted as the definite modification of Peters' method. .) 75 SAMPLES OF VENOUS BLOOD Tube Westergren Venous (4 vols.bmj. 2 3 4 5 4 5 6 6 7 5 6 6 8 8 6 6 7 7 8 9 9 9 8 10 11 12 12 9 14 10 12 14 14 11 12 14 13 15 12* 14 17 14 12* 15 23 21 28 17* 22 26 24 33 27 33 39 39 30 45 42 38 43 55 59 65* 56 47 70* 54 62 65 68 2 3 4 4 5 5 5 6 6 7 7 7 7 7 8 and venous samples from 22 volunteer patients were compared (Table IIIA). 19 and 22) 5 per cent. citrate was substituted. Blood (4 vols. The tendency for an accelerated E. A B 8 8 8 8 8 8 8 9 9 10 10 10 11 Westergren Micro Westergren Micro. . the dilution being kept constant.bmj. 2013 . 4 vols.Downloaded from ard.S. Venous Capillary 4 vols.-For these reasons capillary Micro. sodium citrate gave the most reproducible results when compared with the Westergren method. * Results considered unsatisfactory. though this effect is not constant. Venous 4 vols. The results from fifteen further patients are given in Table IIIB. In view of the clotting that occurred in two samples of capillary blood (Nos. to occur in the microtubes is readily seen. -i 5 per 3-8 per cent. A number of experiments were performed with venous blood using varying proportions of 3 8 and 5 per cent. 5 per cent.com on January 16. Venous (4 vols.) 3 8 per cent. 3*8 per cent. TABLE III (A AND B) CAPILLARY AND VENOUS SEDIMENTATION RATES COMPARED IN 37 PATIENTS Patients Group Tube .Published by group. These experiments led to the following observations: (1) A dilution of 5 vols blood with I vol. aid recognition of slightly increased sedimentation rates..) Citrate (1 vol.com 236 TABLE II ANNALS OF THE RHEUMATIC DISEASES (b) Capillary Blood.. Blood Citrate .) l 2 3 4 S 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32 33 34 35 36 37 38 39 40 41 42 43 44 45 46 47 48 49 50 51 52 53 54 55 56 57 58 59 60 61 62 63 64 65 66 67 68 69 70 71 72 3 8 per cent. an effort was made to find a citrate concentration and dilution at which this occurred. 3*8 per cent. as Ham and Curtis have shown that such a substitution is without effect on the sedimentation rate of venous blood. sodium citrate. if constant. I vol. I Vol.R. vol.

In this way. and only the gentlest squeezing is per.Published by group. 2013 . preferably No patient who appeared with mercury. gren missible (a second operator to steady the lobe and Venous Venous Venous . these microtubes were invariably slower than pipette as described for capillary blood. blood. 0 15 ml.. 4 volS. 1943).. independent readings were made 25 25 63 88 15 20 during this trial by two observers. (marks "A" and "B"). An unbroken column free from air 18 45 65 18 10 13 47 19 74 19 10 16 bubbles is essential. alcohol. 5 vols. Blood difficult to obtain: small clots . The pipette should be cleaned 28 21 35 33 with distilled water. another 10 22 10 7 38 8 watch glass of equal diameter being put over it 11 11 44 7 29 13 53 12 8 7 12 29 (total volume 0 3 ml. 1 vol. 13 35 62 8 13 11 14 14 39 70 8 13 5 per cent.) At 28 17 85 105 28 7* 29 29 95 125 18 23 the completion of the test. cent. The results the corresponding Westergren values (some. cent.com ESTIMATING ER YTHROC YTE SEDIMENTATION RATE OF CAPILLARY BLOOD 237 (2) Using a solid anticoagulant. citrate solution in the 0 2 ml.bmj. mark by means of 16 45 16 9 62 13 17 17 45 62 9 14 a small teat. The tubes are put up in a Westergren 15 21 77 21 53 12 22 54 22 82 13 21 stand and read after 1 hour with a millimetre ruler. I vol. vol. 55 79 23 13 24 23 24 57 24 92 14 30 (When possible.gren . and acetone between 36 37 22 37 24 30 each sample. The pipette is TABLE IV (A AND B) slightly overfilled to mark "A" with 5 per cent. WesterMicro Wester Mir. the microtubes were read first. the blood-citrate mixture 30 30 130 134 18 26 should be run into blotting-paper (as suggested by 23 331 19 32 19 15* Montgomery. cotton-wool.Micro. the citrate 3 8 3 16 3 5 14 4 4 9 4 3 solution is in contact with the maximum amount 14 21 4 5 5 4 of blood. present. I vol. The microtubes are most con15 40 53 9 15 11 veniently filled to the 200 mm.com on January 16. the end wiped with cotton-wool. The pipette is filled 3-8 per 5 per 5 per . and compared (Table IVB). Capillary blood (B) CAPILLARY AND VENOUS SEDIMENTATION is obtained by ear-lobe puncture with a straight RATES (mm. of the blood-citrate Citrate cent. Freely-flowing capillary blood is essential. (b) Results with Capillary Blood.Downloaded from ard./hr). 41 51 45 41 54 54 46 76 (a) Results with Venous Blood. 2 Haagedorn needle. mark. London. with cold tap water and 41 31 52 42 33 53 distilled water. and marks etched at 0-05 ml. citrate).) COMPARED IN FIFTY PATIENTS No. The microtubes are conveniently 38 25 36 39 26 41 cleaned in the same way and at the same time as the 40 30 51 Westergren tubes. after the lobe has been cleaned with spirit and briskly rubbed with dry Patients A B Group . mixture is expelled on to a waxed watch glass.Tube . as the presence of small clots 33 20 32 34 21 invalidates the test. pipette should be calibrated. * Results unsatisfactory. Excess water should be shaken 43 35 48 44 out before the tubes are dried in an oven. gren method (Table IVA). and the pipette is then refilled with capillary blood from 1 1 6 9 2 2 2 12 2 8 3 3 Mark A to Mark B.were compared with those obtained by the Westertimes by as much as 45 mm.-Capillary and Description of the Modified Peters' Method venous samples from a further fifty patients were A 0-2 ml.-Venous blood 47 67 55 48 61 90 from thirty patients was collected in plain venules* 49 84 107 and diluted immediately with the appropriate 50 109 123 * Obtainable from Bayer Products. the results with quantity of 5 per cent. pipette is a great advantage).. that is.: 0-25 ml. cent.. 0 05 ml. 5 vols. Capillary encourage the flow of blood while the first fills the Blood 4 vols. when this was 26 170 92 26 15 21 77 27 27 95 15 31 impracticable.15 ml. 0. and the (A) VENOUS BLOOD DILUTED PATIENTS IN THIRTY citrate level adjusted to mark "A". AS FOR CAPILLARY BLOOD citrate.3-8 per to the 0-2 ml. Blood and citrate are then gently but 6 14 24 6 4 4 7 7 30 4 15 5 thoroughly mixed and left to stand for 3 to 5 17 8 8 22 5 7 17 41 9 9 6 10 minutes (not longer) in the watch glass. Ltd.bmj. and this is easily achieved with 20 51 20 11 65 18 practice.

this relationship was reversed after a further 10 minutes and for the remaining period. have been found to correspond to Westergren values of 15 mm. In these patients. indeed.. It can be seen that though capillary results of 20 and 31 mm. The acceleration that occurred in the microtubes was reproducible when 5 vols blood were diluted with 1 vol. Discussion In the 5 months during which this study was in progress. All the patients who volunteered to take part in this study were adults.R./ hr )OBY WESTERGREN METHOD Figure.com 238 ANNALS OF THE RHEUMATIC DISEASES ill was asked to co-operate in this trial.com on January 16. for example.bmj.R.Published by group. these results would have been reported as equivalent to the following Westergren values.S. citrate.S. the standard Westergren value may be calculated by taking the mid-point through the curves drawn in the Figure (these limits are curved because of the effect of erythrocyte packing at the higher sedimentation rates). it was observed that: (I) The acceleration in the microtubes is constant within narrow limits (Figure) when the Westergren E.R. reading is 50 mm.200) in whom venepuncture had been unsuccessfully attempted on at least one occasion in the past.). 5 per cent. The claims of Peters (1945) are investigated and a modification of his method is described. of cases will be 33±6 mm. of patients attending a Department of Physical Medicine.s and those which were compared with the Westergren method. presumably because of a slight prolongation of the phase of aggregation./hr. From data obtained when results by this method. and has proved of value in the six cases mentioned. blood and 0 05 ml. venepuncture was not attempted. six patients were seen (out of approximately 1. the micro-E.-Sedimentation rates by Westergren and modified Peters' methods. 11 * * '3 ll @ From the observed micro-E.. but this modification of Peters' method could be adapted for paediatric use. analysis of the most divergent points shows that in no case would the clinician have been significantly misled if the Westergren values as calculated from the microE. - 10 20 30 40 50 60 70 80 90 100 110 120 130 SEDIMENTATION RATES (mm . accounts for the number of normal values obtained.R. where small clots occurred and results were unreliable. except in the two cases marked with an asterisk.bmj. 2013 .S. A satisfactory result was obtained from finger-prick blood in the one patient in whom this method was used. In two.R. 140130 v 110' 0 w 90. were compared with results . and in no case were differences noted between the behaviour of these micro-E. 1956b).R.S. Tubes of an internal diameter of 125 mm. results were obtained that were consistent with the clinical picture.Downloaded from ard. is raised. L- 5 E > 40 '. These observations showed that though sedimen- Summary An account is given of some common methods employed for determining the erythrocyte sedimentation rate of capillary blood. then the Westergren value in over 90 per cent. have given reliable results. 0- i-. If. However. In certain cases. values had been the only data available. This method was designed for estimating the E.302 20I . and the results obtained were capable of conversion at all sedimentation rates into the corresponding Westergren values with more accuracy than those obtained by the technique described by Peters. that requires 0-25 ml. and 19±4 mm. serial readings were taken of the cases compared in Table IV at 10-minute intervals. 5 per cent. using capillary blood (fifty patients) and venous blood (thirty patients). Ear-lobe puncture is less painful and provides blood more readily (Dacie. Puncture of the ear-lobe was used in preference to that of the finger pulp in every patient except one (who had very small lobes). (2) Capillary and venous samples give results that are strictly comparable.S.S.. In all six patients capillary blood was easily obtainable and their preference for this procedure was emphatic./100 ml.. and this holds true for samples from non-anaemic patients (Hb 13 to 15 g. and this tation at 10 minutes might be slower in the microtubes./hr. Na citrate. 13±3 mm.

a todas las velocidades de sedimentaci6n. REFERENCES Cutler. J. London. Med. H. 756. S. Ann. J. intern. Bodian of the Hospital for Sick Children. 5. M. clin. (1941). R. las cifras que se obtiene con el metodo de Westergren. A.. I am also most grateful to Mrs. Kroll for much technical assistance.. 657. Triangle. C.. Duxbury. M. Smith.Child. (1933). 151. med.com ESTIMATING ERYTHROCYTE SEDIMENTATION RATE OF CAPILLARY BLOOD 239 by the Westergren method. rheum. (1943). Nichols. L. Martensson. Sci. 23. Sci. Lab. (1956b). 211. 447. 691. Great Ormond Street.59.. J. M.. (1945). Med. E. 206. 1317. Amer. (1957).05 c.c. G. Landau. 192. 687. employant du sang capillaire (50 malades) et veineux (30 malades). Lab. 25.. M.J. Lab. Path. clin. London. J. Ibid. qui demandait 0..bmj. de citrate de soude. Al comparar los resultados con este metodo. Westergren.25 c. 20. 13. Acta med. Thygesen. C. (1921). (1935). E. 173. med. montre que la micro-methode permet de prevoir precisement. 189.bmj. R.. 105. Determinacion de-la vitesse de sedimentation erythrocytaire du sang capillaire par un nouveau procede RESUME On decrit quelques procedes habituels pour determiner la vitesse de sedimentation erythrocytaire du sang capillaire. Lab. 1. med. p.. 2nd ed. H. Med. de sang et 0. 247. 980. J. L. scand. 27. J. 102. Sci. Obermer. J.. Determinaci6n de la velocidad de sedimentaci6n eritrocitaria de la sangre capilar por un nuevo metodo SUMARIO Se describen algunos procedimientos habituales para determiner la velocidad de sedimentaci6n eritrocitaria de la sangre capilar. empleando la sangre capilar (50 enfermos) y venosa (30 enfermos) a los obtenidos con el metodo de Westergren. and Hansen. (1956a). F. 7. M. also Dr. 28.. scand. E. J. Peters. W. and Whyte. 75. A. Dacie. T. W. 12. 2013 . A. W. Med. 1842. (1955).Downloaded from ard. P.05 c. (1927). Medicine (Baltimore). Med. 734. H. Lancet. Se estudian los resultados de Peters (1945) y se describe una modificaci6n de su metodo. clin. 355. Acta med. H. 424. 146. (1936). a ceux qu'on obtient avec la methode de Westergren. Dis. I should like to thank the patients and physicians of the Arthur Stanley Institute for Rheumatism. Ibid. Kato. and Curtis.. que requeria 0. Med. 27. (1938). E.Dis. de sangre y 0. a toutes les vitesses de sedimentation. (1940). Masters of the Paddington Green Children's Hospital. . for their co-operation. Peto Place. (1942). Lawrence. K. Lancet. 115. McSweeney. J. les chiffres donnas par la methode de Westergren. de citrato de sodio. (1934). for descriptions of their methods. L. sectn..Published by group. J. clin. J. (1943). 45. 2. 54. Wintrobe.c. Practitioner. Amer. and Dr. 1. M.c. (1942). Amer. Amer.1. V. Montgomery. (1938) Ibid. Churchill... La comparaison des resultats de ce procede. (1957). (1953). Ham. p.. McD. 134. se ve que el micro-metodo permite anticipar con precision.25 c. J. (1943). Herzog. Rogatz. Austr.. C.. -(1940). On etudie les resultats de Peters (1945) et on decrit une modification de son procede. 164.c. 43... J. Arch.. J. 73. J. Tech. L. it is shown that accurate prediction of the Westergren values is possible at all rates of sedimentation with the use of this micro-method. Goldberger. "Practical Haematology". E. Ibid. S.. and Landsberg. Suppl. 17. (1953). H. clin.com on January 16. J. 3. T. J.310. Amer. Nelson.

com Estimation of the Erythrocyte Sedimentation Rate of Capillary Blood : Description of a New Method H. D.com/group/rights-licensing/permissions To order reprints go to: http://journals.234 Updated information and services can be found at: http://ard.bmj.17.2.bmj.bmj. Lloyd Ann Rheum Dis 1958 17: 234-239 doi: 10.1136/ard.bmj.bmj.com/content/17/2/234.com/cgi/reprintform To subscribe to BMJ go to: http://group.Downloaded from ard.bmj.com/subscribe/ . E.com on January 16. Sign up in the box at the top right corner of the online article. Notes To request permissions go to: http://group. 2013 .Published by group.citation These include: Email alerting service Receive free email alerts when new articles cite this article.