Complete blood count

A complete blood count (CBC), also known as a com-

plete blood cell count, full blood count (FBC), or
full blood exam (FBE), is a blood panel requested
by a doctor or other medical professional that gives
information about the cells in a patient’s blood, such as the
cell count for each cell type and the concentrations of var-
ious proteins and minerals. A scientist or lab technician
performs the requested testing and provides the request-
ing medical professional with the results of the CBC.
Blood counts of various types have been used for clinical
purposes since the 19th century. Automated equipment CBC being performed in a hospital using an Abbott Cell-Dyn
to carry out complete blood counts was developed in the 1700 automatic analyzer.
1950s and 1960s.[1]
The cells that circulate in the bloodstream are gen-
erally divided into three types: white blood cells clotting. The sample is then transported to a laboratory.
(leukocytes), red blood cells (erythrocytes), and platelets Sometimes the sample is drawn off a finger prick using
(thrombocytes). Abnormally high or low counts may in- a Pasteur pipette for immediate processing by an auto-
dicate the presence of many forms of disease, and hence mated counter.
blood counts are amongst the most commonly performed In the past, counting the cells in a patient’s blood was
blood tests in medicine, as they can provide an overview performed manually, by viewing a slide prepared with a
of a patient’s general health status. A CBC is routinely sample of the patient’s blood (a blood film, or periph-
performed during annual physical examinations in some eral smear) under a microscope. Presently, this process
jurisdictions. is generally automated by use of an automated analyzer,
with only approximately 10–20% of samples now being
examined manually.
1 Medical uses
2.1 Automated blood count
Complete blood counts are done to monitor overall
health, to screen for some diseases, to confirm a diag-
nosis of some medical conditions, to monitor a medical
condition, and to monitor changes in the body caused by
medical treatments.[2]
For patients who need blood transfusion, a blood count
may be used to get data which would help plan an amount
of treatment.[3] In such cases, the person should have only
one blood count for the day, and the transfusion of red
blood cells or platelets should be planned based on that.[3]
Multiple blood draws and counts throughout the day are
an excessive use of phlebotomy and can lead to unnec-
essary additional transfusions, and the extra unnecessary
treatment would be outside of medical guidelines.[3]

Complete blood count performed by an automated analyser. Dif-

2 Procedure ferentials not seen here.

A phlebotomist collects the sample through venipuncture, Most blood counts today include a CBC count and leuko-
drawing the blood into a test tube containing an cyte differential count (LDC) (that is, not just the to-
anticoagulant (EDTA, sometimes citrate) to stop it from tal WBC count but also the count of each WBC type,

1
2 2 PROCEDURE

such as neutrophils, eosinophils, basophils, monocytes,

and lymphocytes). More sophisticated modern analyzers
can provide extended differential counts, which include
hematopoietic progenitor cells, immature granulocytes,
and erythroblasts.[4]
The blood is well mixed (though not shaken) and placed
on a rack in the analyzer. This instrument has flow cells,
photometers and apertures that analyze different elements
in the blood. The cell counting component counts the
numbers and types of different cells within the blood. The
results are printed out or sent to a computer for review.
Blood counting machines aspirate a very small amount
of the specimen through narrow tubing followed by an
aperture and a laser flow cell. Laser eye sensors count Manual blood counts use a light microscope, usually with a spe-
the number of cells passing through the aperture, and cialized microscope slide, which is called a hemocytometer.
can identify them; this is flow cytometry. The two main
sensors used are light detectors and electrical impedance.
The instrument measures the type of blood cell by ana-
lyzing data about the size and aspects of light as they pass
through the cells (called front and side scatter). Other in-
struments measure different characteristics of the cells to
categorize them.
Because an automated cell counter samples and counts
so many cells, the results are very precise. However, cer-
tain abnormal cells in the blood may not be identified cor-
rectly, requiring manual review of the instrument’s results
and identification of any abnormal cells the instrument
could not categorize.
In addition to counting, measuring and analyzing red
blood cells, white blood cells and platelets, auto-
This shows the view through the microscope of the specialized
mated hematology analyzers also measure the amount
hemocytometer slide. The built-in grid simplifies counting cells
of hemoglobin in the blood and within each red blood by helping the technician keep track of which cells have already
cell. This is done by adding a diluent that lyses the cells been counted.
which is then pumped into a spectro-photometric mea-
suring cuvette. The change in color of the lysate equates
to the hemoglobin content of the blood. This informa- the total number of white blood cells, the absolute num-
tion can be very helpful to a physician who, for example, ber of each type of white cell can be obtained.
is trying to identify the cause of a patient’s anemia. If the
Manual counting is useful in cases where automated ana-
red cells are smaller or larger than normal, or if there is
lyzers cannot reliably count abnormal cells, such as those
a lot of variation in the size of the red cells, this data can
cells that are not present in normal patients and are only
help guide the direction of further testing and expedite
seen in peripheral blood with certain haematological con-
the diagnostic process so patients can get the treatment
ditions. Manual counting is subject to sampling error be-
they need quickly.
cause so few cells are counted compared with automated
analysis. A manual count will also give information about
other cells that are not normally present in peripheral
2.2 Manual blood count blood, but may be released in certain disease processes.
Medical technologists examine blood film via a micro-
Hemocytometers (counting chambers that hold a speci- scope for some CBCs, not only to find abnormal white
fied volume of diluted blood and divide it with grid lines) cells, but also because variation in the shape of red cells
are used to calculate the number of red and white cells is an important diagnostic tool. Although automated
per litre of blood. (The dilution and grid lines are needed analysers give fast, reliable results regarding the num-
because there are far too many cells without those aids.) ber, average size, and variation in size of red blood cells,
To identify the numbers of different white cells, a blood they do not detect cells’ shapes. Also, some normal pa-
film is made, and a large number of white blood cells (at tients’ platelets will clump in EDTA anticoagulated blood,
least 100) are counted. This gives the percentage of cells which causes automatic analyses to give a falsely low
that are of each type. By multiplying the percentage with platelet count. The person viewing the slide in these cases
3.2 Red cells
will see clumps of platelets and can estimate if there are
low, normal, or high numbers of platelets.
3 Included tests
A scanning electron microscope (SEM) image of normal circu-
lating human blood. One can see red blood cells, several knobby
white blood cells including lymphocytes, a monocyte, a neu-
trophil, and many small disc-shaped platelets.
A complete blood count will normally include:
3.1 White cells
• Total white blood cells are reported, and a differen-
tial reports all the white cell types as a percentage
and as an absolute number per litre.[5] A high WBC
may indicate an infection.
• Neutrophils: May indicate bacterial infection.
May also be raised in acute viral infections.
Because of the segmented appearance of the
nucleus, neutrophils are sometimes referred to 3.5 MCV
as “segs”. The nucleus of less mature neu-
trophils is not segmented, but has a band or
rod-like shape. Less mature neutrophils—
those that have recently been released from
the bone marrow into the bloodstream—are
known as “bands” or “stabs”. Stab is a Ger-
man term for rod.[6]
• Lymphocytes: Higher with some viral in-
fections such as glandular fever. Raised in
chronic lymphocytic leukemia (CLL). Can be
3
decreased by HIV infection. In adults, lym-
phocytes are the second most common WBC
type after neutrophils. In young children un-
der age 8, lymphocytes are more common than
neutrophils.[6]
• Monocytes: May be raised in bacterial infec-
tion, tuberculosis, malaria, Rocky Mountain
spotted fever, monocytic leukemia, chronic
ulcerative colitis and regional enteritis[6]
• Eosinophils: Increased in parasitic infections,
asthma, or allergic reaction.
• Basophils: May be increased in bone mar-
row related conditions such as leukemia or
lymphoma.[6]
3.2 Red cells
• Total red blood cells: The number of red cells is
given as an absolute number per litre.[5] Iron defi-
ciency anemia shows up as a Low RBC count.
• LOINC codes for Whole Blood RBC Count-
ing
3.3 Hemoglobin
• Hemoglobin: The amount of hemoglobin in the
blood, expressed in grams per decilitre.[5] A low
level of hemoglobin is a sign of anemia.
• LOINC codes for this test (Note: not all the
codes in the search result are suitable for this
test.)
3.4 Hematocrit
• Hematocrit or packed cell volume (PCV): This is the
fraction of whole blood volume that consists of red
blood cells.[5]
• Red blood cell indices[7]
• Mean corpuscular volume (MCV): the average vol-
ume of the red cells, measured in femtolitres.[5]
Anemia is classified as microcytic or macrocytic if
the MCV value is above or below the expected nor-
mal range; anemias are classified as normocytic if
the MCV is within the expected range. Other con-
ditions that can affect MCV include thalassemia,
reticulocytosis, alcoholism, chemotherapy, vitamin
B12 deficiency, and/or folic acid deficiency.
4 7
3.6 MCH
• Mean corpuscular hemoglobin (MCH): the aver-
age amount of hemoglobin per red blood cell, in
picograms.[5]
3.7 MCHC
• Mean corpuscular hemoglobin concentration
(MCHC): the average concentration of hemoglobin
in the cells.
3.8 RDW
• Red blood cell distribution width (RDW): the vari-
ation in cellular volume of the RBC population.
3.9 Platelets
• Platelet numbers are given, as well as information
about their size and the range of sizes in the blood.[5]
• Mean platelet volume (MPV): a measurement of the
average size of platelets.
4 Results
An example report format for a complete blood count.
Note that test names, measurement units and reference
ranges may vary between countries and laboratories. Pa-
tient results should always be interpreted using the units
and reference ranges from the laboratory that produced
the results.
Example of reference ranges for blood tests of white blood
cells.[8]
5 Interpretation
Certain disease states are defined by an absolute increase
or decrease in the number of a particular type of cell in
the bloodstream. For example:
Many disease states are heralded by changes in the blood
count:
• Leukocytosis can be a sign of infection
• Thrombocytopenia can result from drug toxicity
EXTERNAL LINKS
• Pancytopenia is generally referred to as the result of
decreased production from the bone marrow, and is
a common complication of cancer chemotherapy
6 References
[1] Verso, ML (May 1962). “The Evolution of Blood Count-
ing Techniques” (PDF). Read at a meeting of the Sec-
tion of the History of Medicine, First Australian Medical
Congress 8: 149–58. doi:10.1017/s0025727300029392.
PMC 1033366. PMID 14139094. Retrieved 9 Septem-
ber 2013.
[2] Mayo Clinic (14 February 2014). “Complete blood count
(CBC) Why it’s done - Tests and Procedures”. may-
oclinic.org. Retrieved 29 July 2014.
[3] American Association of Blood Banks (24 April 2014),
“Five Things Physicians and Patients Should Question”,
Choosing Wisely: an initiative of the ABIM Foundation
(American Association of Blood Banks), retrieved 25 July
2014, which cites
• Napolitano, LM; Kurek, S; Luchette, FA; Cor-
win, HL; Barie, PS; Tisherman, SA; Hebert,
PC; Anderson, GL; Bard, MR; Bromberg, W;
Chiu, WC; Cipolle, MD; Clancy, KD; Diebel,
L; Hoff, WS; Hughes, KM; Munshi, I; Nayduch,
D; Sandhu, R; Yelon, JA; American College of
Critical Care Medicine of the Society of Criti-
cal Care, Medicine; Eastern Association for the
Surgery of Trauma Practice Management, Work-
group (Dec 2009). “Clinical practice guideline:
red blood cell transfusion in adult trauma and
critical care.”. Critical Care Medicine 37 (12):
3124–57. doi:10.1097/CCM.0b013e3181b39f1b.
PMID 19773646.
[4] Buttarello, M; Plebani, M (Jul 2008). “Automated
blood cell counts: state of the art.”. Ameri-
can journal of clinical pathology 130 (1): 104–
16. doi:10.1309/EK3C7CTDKNVPXVTN. PMID
18550479.
[5] David C., Dugdale (19 March 2012). “CBC: MedlinePlus
Medical Encyclopedia”. MedlinePlus. United States Na-
tional Library of Medicine. Retrieved 29 July 2014.
[6] “Complete Blood count with Differential”. RbCeus.com.
2013. Retrieved 2014-11-21.
[7] “RBC indices”. MedlinePlus: U.S. National Library of
Medicine. Retrieved 1 June 2013.
[8] References at Reference ranges for blood tests#White
blood cells 2
7 External links
• Blood Groups and Red Cell Antigens—Free online
book at NCBI Bookshelf ID: NBK2261
• Complete Blood Count—Lab Tests Online
 5

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