Changes in Automated Complete Blood Cell Count and
Differential Leukocyte Count Results Induced by
Storage of Blood at Room Temperature
Gene L. Gulati, PhD; Lawrence J. Hyland, MD; William Kocher, MD; Rolland Schwarting, MD
● Objective.—To delineate changes that occur in various
parameters of automated complete blood cell count (CBC)
and differential leukocyte count (differential) on prolonged
storage of blood at room temperature.
Design.—A CBC and an automated differential were per-
formed on the Coulter Gen.S on 40 K3 (tripotassium
ethylenediamine-tetraacetate) EDTA-anticoagulated blood
specimens once daily, specimen volume permitting, for 3
to 7 days. Specimens were kept at room temperature
throughout the study. The results were tabulated using a
personal computer with Excel software. Percent change or
absolute difference from the initial value for each param-
eter for each subsequent day of the study period was cal-
culated.
Results.—Among the CBC parameters, hemoglobin, red
blood cell count, and mean corpuscular hemoglobin were
stable for the duration of the study (7 days), white blood
cell count was stable for at least 3 days (up to 7 days, if
C linical laboratory professionals are familiar with the
scenario whereby a blood specimen is collected on a
Friday but not delivered to the laboratory for processing
until the following Monday or even later. When such a
specimen arrives at the laboratory, the staff needs to de-
cide (1) whether to accept or reject it; (2) if accepted,
whether to perform all of the ordered tests or only those
deemed appropriate based on the age of the specimen;
and (3) what comments, if any, should be appended to the
reported results regarding their reliability or unreliability.
Such decision making requires laboratorians to be familiar
with changes known to occur in blood specimens during
storage. Manufacturers of automated analyzers and pub-
lished literature often cite that blood specimens, kept at
either room temperature or at 48C (refrigerated) for up to
24 hours, generally yield reliable results for complete
blood cell count (CBC) and automated differential leuko-
cyte count (differential).1–4 However, specific information
concerning the suitability or unsuitability of specimens
older than 1 day for various laboratory tests, including the
Accepted for publication October 19, 2001.
From the Department of Pathology, Anatomy, and Cell Biology,
Jefferson Medical College, Thomas Jefferson University, Philadel-
phia, Pa.
Reprints: Gene L. Gulati, PhD, 307 Pavilion Bldg, Thomas Jefferson
University Hospital, 125 S 11th St, Philadelphia, PA 19107 (e-mail:
gene.gulati@mail.tju.edu).
336 Arch Pathol Lab Med—Vol 126, March 2002
the count was within or above the normal range), and
platelet count was stable for at least 4 days (up to 7 days,
if the count was within or above the normal range). The
mean corpuscular volume, mean platelet volume, hemat-
ocrit, and red blood cell distribution width each increased,
and the mean corpuscular hemoglobin concentration de-
creased from day 2 onward. Among the differential param-
eters, the relative percentages and absolute numbers of
neutrophils, lymphocytes, and eosinophils tended to in-
crease, whereas those of monocytes trended downward
over time. Limited data on basophils did not reveal an ap-
preciable change.
Conclusion.—Blood specimens stored at room temper-
ature for more than 1 day (up to 3 days or possibly longer)
were found to be acceptable with some limitations for CBC
but not for the differential.
(Arch Pathol Lab Med. 2002;126:336–342)
CBC and the automated differential, is scarce, particularly
in the recent literature. This study delineates changes that
occur in various parameters of automated CBC and dif-
ferential during storage of blood at room temperature for
several days.
MATERIALS AND METHODS
A total of 40 K3 (tripotassium ethylenediamine-tetraacetate)
EDTA-anticoagulated blood specimens were processed through
the Coulter Gen.S (Beckman Coulter, Miami, Fla) for CBC and
differential once daily, specimen volume permitting, for 3 to 7
days. Specimens were selected from the routine laboratory work-
load over several days to represent a range of normal and ab-
normal CBC and differential values, as indicated in Table 1.
Among the 40 specimens, 11 were leukopenic (white cell count,
,4.0 3 103/mL), 16 had leukocytosis (white cell count, .11.0 3
103/mL), 15 were thrombocytopenic (platelet count, ,140 3 103/
mL), and 11 had thrombocytosis (platelet count, .400 3 103/mL).
All but 4 specimens were anemic, with hemoglobin levels less
than 12.5 g/dL. Specimens were kept at room temperature
throughout the study. The Coulter Gen.S uses impedance tech-
nology to generate a 10-part CBC and volume (impedance), con-
ductivity, and light scatter measurements, commonly referred to
as VCS technology, to generate a 5-part differential.1 Software
versions 1C and 2A were used during this evaluation. Calibration
and quality control of the analyzer were performed using S-cal
and 3 levels of 5C control (both from Beckman Coulter), respec-
tively, according to the manufacturer’s instructions.1 The 10-part
CBC consisted of white blood cell count (WBC), red blood cell
count (RBC), hemoglobin, hematocrit, mean corpuscular volume
Automated CBC and Differential Result Changes—Gulati et al
 Table 1. Range of Initial Automated CBC and some of the values obtained initially and/or on subsequent days
Differential Results of Specimens Included in were 0. Ultimately, mean percent change or difference and SD
the Study* were determined, also using Excel software, for each parameter
for each day. Adobe Illustrator, version 8.0, was used to prepare
Parameter Range the figures.
CBC
WBC, 103/mL 0.3–67.9
RESULTS
RBC, 106/mL 1.91–5.43 Changes observed in the CBC results of blood speci-
Hemoglobin, g/dL 6.2–16.4 mens stored at room temperature are summarized in Ta-
Hematocrit, % 17.9–47.3
MCV, mm3 68–110
ble 2 and illustrated in Figure 1. For each CBC parameter,
MCH, pg 21.5–37.4 mean percent change from the value on day 0 is plotted
MCHC, g/dL 31.3–36.2 along with its 95% confidence interval (CI) (62 SDs)
RDW, % 12.3–28.7 against time in days after collection of blood (Figure 1).
Platelet count, 103/mL 14–850 The mean percent change in the WBC was less than 1
MPV, mm3 6.2–10.4 for the first 3 days but fluctuated between 25.3 and 16.3
Differential from days 4 to 7. The 95% CIs ranged between 212.2%
Neutrophils, % 23.2–94.9 and 113.8% for the first 3 days and between 230% and
Lymphocytes, % 1.5–69.2 142% from days 4 to 7.
Monocytes, % 0.1–29.0 The RBC, hemoglobin, and MCH were relatively stable,
Eosinophils, % 0.0–9.3
Basophils, % 0.0–1.7
each with a mean percent change of equal to or less than
Neutrophils, No. 0.1–62.6 1.1 and a combined 95% CI in the range of 23.7% to
Lymphocytes, No. 0.1–6.2 15.1%.
Monocytes, No. 0.0–2.1 The MCV, hematocrit, and RDW each increased over
Eosinophils, No. 0.0–1.5 time, revealing maximum mean percent changes on day 7
Basophils, No. 0.0–1.1 of 10.4, 10.3, and 15.8, respectively. The respective 95%
* CBC indicates complete blood cell count; WBC, white blood cell CIs for MCV, hematocrit, and RDW ranged from 21.8%
count; RBC, red blood cell count; MCV, mean corpuscular volume; to 114.8%, 22.8% to 116.5%, and 25.4 % to 125.7%
MCH, mean corpuscular hemoglobin; MCHC, mean corpuscular he-
moglobin concentration; RDW, red blood cell distribution width; and
throughout the 7-day period.
MPV, mean platelet volume. The MCHC trended downward over time, with a max-
imum mean percent change of 29.4 on day 7 and 95% CIs
of 213.9% to 13.2% for the 7-day period.
(MCV), mean corpuscular hemoglobin (MCH), mean corpuscular The mean percent change in the platelet count fluctu-
hemoglobin concentration (MCHC), red cell distribution width ated between 20.9 and 14.3 for the first 4 days and
(RDW), platelet count, and mean platelet volume (MPV). The 5- ranged from 16.1 to 16.6 for the subsequent 3 days. Sim-
part differential consisted of relative percentages and absolute ilarly, the 95% CIs ranged from 223.8% to 130.2% for the
numbers of neutrophils, lymphocytes, monocytes, eosinophils, initial 4 days and from 242.5% to 154.8% for the subse-
and basophils.
quent 3 days. The platelet count of 2 of the 40 specimens
The CBC and differential results were tabulated using a per-
sonal computer with Excel software. Percent change from the day dropped progressively (up to 37% of the value on day 0)
0 value for each parameter for each subsequent day of the study from day 3 onward, and on blood smear review was found
period was calculated. For percentages and numbers of eosino- to be associated with platelet clumping. Only a slight in-
phils, basophils, and monocytes, absolute difference rather than crease in mean percent change and either no change or
percent change from the value on day 0 was calculated because minimal decrease in SD was noted on each day when the

Table 2. Mean Percent Changes in CBC Parameters Induced by Storage of Blood at Room Temperature*
Day 0
(n 5 Day 1 Day 2 Day 3 Day 4 Day 5 Day 6 Day 7
Parameter 40) (n 5 40†) (n 5 40) (n 5 37) (n 5 15‡) (n 5 24) (n 5 16) (n 5 12)
WBC 0.0 20.9 (5.5) 20.1 (5.7) 0.8 (6.5) 25.3 (5.6) 4.6 (17.3) 6.3 (17.8) 1.5 (9.9)
RBC 0.00 20.34 (1.19) 20.61 (1.08) 20.11 (1.61) 0.14 (1.93) 0.13 (1.04) 0.11 (1.11) 0.07 (1.26)
Hemoglobin 0.0 20.4 (1.2) 20.7 (1.0) 20.6 (0.9) 1.0 (1.2) 20.3 (0.9) 0.2 (0.8) 0.2 (0.9)
Hematocrit 0.0 1.1 (2.0) 3.4 (2.2) 6.0 (2.5) 8.4 (2.7) 8.6 (2.5) 9.9 (2.7) 10.3 (3.1)
MCV 0.0 1.5 (1.7) 4.0 (2.1) 6.2 (2.4) 8.3 (2.2) 8.5 (2.1) 9.6 (2.2) 10.4 (2.2)
RDW 0.0 4.3 (3.2) 8.0 (6.6) 9.5 (7.4) 7.9 (4.8) 12.1 (5.2) 14.2 (4.1) 15.8 (5.0)
MCH 0.0 0.0 (1.5) 0.0 (1.3) 20.4 (1.7) 1.1 (2.0) 20.4 (1.0) 0.1 (1.0) 0.0 (1.1)
MCHC 0.0 21.5 (2.3) 23.9 (2.1) 26.1 (2.3) 26.6 (2.2) 28.2 (2.2) 28.8 (2.2) 29.4 (2.3)
Platelet count 0.0 20.2 (9.0) 4.3 (12.9) 2.6 (13.2) 20.9 (10.5) 6.6 (23.6) 6.3 (21.1) 6.1 (24.3)
PLTa 0.0 20.1 (9.2) 4.6 (13.2) 3.5 (13.0) 0.3 (9.7) 10.0 (21.4) 9.3 (18.3) 10.1 (21.1)
MPV 0.0 5.4 (6.9) 10.8 (10.6) 11.1 (11.0) 12.0 (12.0) 12.5 (12.3) 6.3 (6.3) 8.2 (8.2)
* Data are presented as mean (SD). CBC indicates complete blood cell count; WBC, white blood cell count; RBC, red blood cell count; MCV,
mean corpuscular volume; RDW, red blood cell distribution width; MCH, mean corpuscular hemoglobin; MCHC, mean corpuscular hemoglobin
concentration; PLTa , platelet data after excluding 2 specimens that revealed a drop in platelet count associated with platelet clumping; and MPV,
mean platelet volume.
† Number of specimens on day 1 was 39 for platelet count and 38 for MPV because for unknown reasons the analyzer voted out the platelet
count on 1 specimen and did not generate the MPV result on 2 specimens.
‡ Total number of specimens on day 4 is lower than that on day 5 because a run on the Coulter Gen.S was inadvertently missed for a batch of
specimens on day 4.

Arch Pathol Lab Med—Vol 126, March 2002 Automated CBC and Differential Result Changes—Gulati et al 337
Figure 1. Mean (62 SDs) changes observed
in complete blood cell count result on storage
of blood at room temperature. Mean percent
change from the value on day 0 and the 95%
confidence intervals are plotted against time
in days after collection of specimen. The
number of specimens is indicated on top of
the 95% confidence interval bars for each
day. The number of specimens on day 1 was
39 for platelet count (PLT) and 38 for mean
platelet volume (MPV) because for unknown
reasons the analyzer voted out the PLT on 1
specimen and did not generate the MPV re-
sult on 2 specimens. WBC indicates white
blood cell count; RBC, red blood cell count;
MCV, mean corpuscular volume; RDW, red
blood cell distribution width; MCH, mean
corpuscular hemoglobin; MCHC, mean cor-
puscular hemoglobin concentration; and
PLTa, platelet data after excluding 2 speci-
mens that revealed a drop in platelet count
associated with platelet clumping.

platelet count data of these 2 specimens were excluded
from final calculations (PLTa in Table 2 and Figure 1).
The MPV initially increased steadily, reaching a maxi-
mum mean percent change of 112.5 on day 5. On days 6
and 7, the mean percent changes were 16.3 and 18.2,
respectively. The 95% CIs for MPV ranged between
212.0% to 137.1% throughout the 7-day period.
When changes observed in the CBC parameters were
categorized based on whether the initial (day 0) value was
low (below the lowest normal value), normal (within the
normal range), or high (above the highest normal value),
the number of specimens analyzed per day decreased in
each group to between 4 and 16, but certain trends became
evident among the groups. Leukopenic and thrombocy-
topenic specimens revealed the greatest day-to-day mean
percent changes and the widest day-to-day SDs compared
338 Arch Pathol Lab Med—Vol 126, March 2002
with the changes observed for specimens with normal or
high initial respective counts (Table 3). Furthermore, the
platelet counts of thrombocytopenic specimens tended to
increase over time, whereas the opposite was true for
specimens with high initial count (Figure 2, B). Similarly,
the WBC of leukopenic specimens tended to increase from
day 5 onward, whereas the opposite was true, although
minimally so, from day 4 onward for specimens with high
initial counts (Figure 2, A). Changes observed in the re-
maining CBC parameters (data not shown) did not show
any particular relationship to the levels of initial values.
Changes observed in the automated differential results
of blood specimens stored at room temperature are shown
in Table 4 and Figure 3.
A minimal initial decrease in the percentage of neutro-
phils on days 1 and 2 and in the number of neutrophils
Automated CBC and Differential Result Changes—Gulati et al
 Table 3. Subcategorization of Changes in WBC and Platelet Count Induced by Storage of Blood at Room Temperature*
Parameter Day 0 Day 1 Day 2 Day 3 Day 4 Day 5 Day 6 Day 7
WBC
Low (0.3–3.8 3 103/mL)
Mean (SD) 0.0 22.7 (9.7) 0.9 (11.0) 3.7 (11.8) 26.4 (7.9) 12.7 (29.1) 26.0 (28.6) ND
No. of specimens 11 11 11 10 6 8 4 2
Normal (5.5–10.6 3 103/mL)
Mean (SD) 0.0 20.2 (2.2) 20.3 (1.9) 20.9 (1.9) 25.5 (4.8) 0.9 (4.2) 1.1 (6.2) 0.4 (7.9)
No. of specimens 13 13 13 13 5 8 6 6
High (11.5–67.9 3 103/mL)
Mean (SD) 0.0 20.2 (2.8) 20.6 (2.6) 0.2 (2.9) 23.2 (1.4) 0.0 (2.0) 21.5 (2.9) 23.9 (4.8)
No. of specimens 16 16 16 14 4 8 6 4
Platelet count
Low (14–135 3 103/mL)
Mean (SD) 0.0 1.8 (14.3) 10.4 (17.8) 9.8 (17.7) 8.2 (15.2) 27.9 (21.4) 21.4 (15.4) 27.5 (13.4)
No. of specimens 15 14 15 13 4 9 7 5
Normal (152–371 3 103/mL)
Mean (SD) 0.0 0.4 (2.8) 3.0 (6.2) 20.1 (9.2) 24.3 (8.1) 26.8 (15.7) 26.7 (17.4) 27.9 (19.2)
No. of specimens 14 14 14 13 6 11 7 6
Normala (152–371 3 103/mL)
Mean (SD) 0.0 20.2 (2.6) 3.9 (6.3) 2.4 (7.7) 21.5 (5.0) 21.3 (11.0) 21.8 (12.9) 22.1 (14.3)
No. of specimens 12 12 12 11 5 9 6 5
High (403–850 3 103/mL)
Mean (SD) 0.0 22.3 (4.7) 22.4 (7.4) 22.8 (6.3) 24.1 (4.5) 24.7 (5.9) ND ND
No. of specimens 11 11 11 11 5 4 1 1
* WBC indicates white blood cell count; Normala, normal range platelet data after excluding 2 specimens that revealed a drop in platelet count
associated with platelet clumping; and ND, not determined due to inadequate number of specimens.

on day 1 was followed by a variable degree of increase in
both on subsequent days. A maximum mean percent
change in percentage of neutrophils of 121.4 was noted
on day 4 and in number of neutrophils of 124.5 on day
6. The 95% CIs during the 7-day period ranged from
269.9% to 190.8% for the percentage of neutrophils and
from 2119.2% to 1168.1% for the number of neutrophils.
The widest 95% CI was noted on day 6 for both the per-
centage and number of neutrophils.
The percentage and number of lymphocytes tended to
increase over time, and the mean percent change fluctu-
ated between 129.1 and 197.8 for the former and between
13.3 and 181.3 for the latter. The respective CIs for the
percentage and number of lymphocytes throughout the 7-
day period ranged from 2782.3% to 1978% and 2207.5%
to 1355.2%.
The percentage and number of monocytes tended to de-
crease over time. The mean percent change fluctuated be-
tween 285.4 and 10.4 for the former, and the mean ab-
solute difference fluctuated between 20.6 and 20.1 for the
latter. The respective 95% CIs for the percentage and num-
ber of monocytes throughout the 7-day period ranged
from 2406.7% to 1407.5% and 22.9 to 12.8, respectively.
The mean absolute difference from the value on day 0
for the percentage and number of eosinophils increased
steadily with time, with a maximum difference of 17.9 for
the former and 10.6 for the latter, both on day 7. The
respective 95% CIs for the percentage and number of eo-
sinophils ranged from 225.6 to 140.4 and 21.1 to 12.0.
Basophils represented the smallest fraction (0.0% to
1.7%) of all WBC and revealed minimal or no change with
time in both the percentage and number. The maximum
mean absolute difference from the value on day 0 was 0.2
on day 4 for the percentage of basophils. The mean ab-
Arch Pathol Lab Med—Vol 126, March 2002
solute difference from the value on day 0 for the number
of basophils remained unchanged at 0 throughout the
study. The respective 95% CIs for the mean difference in
the percentage and number of basophils ranged from
21.4 to 11.5 and 20.4 to 10.3.
COMMENT
Storage of blood at room temperature for up to 7 days
caused changes in CBC and automated differential results.
However, the changes observed in some CBC parameters
may be considered clinically insignificant.
The maximum change of 4% in RBC, 3.4% in hemoglo-
bin, and 5.1% in MCH carries little, if any, clinical signif-
icance. Moreover, the narrow 95% CIs for each of these 3
parameters clearly demonstrate their stability at room
temperature for at least up to 7 days. The MCV, and con-
sequently the hematocrit and RDW, increased over time,
at an apparently faster rate during the first 4 days when
compared with that during the subsequent 3 days. The
increase in MCV reflects red blood cell swelling at room
temperature. The degree of change in MCV, hematocrit,
and RDW observed from day 2 onward may be considered
less than desirable, particularly when the results are bor-
derline normal or abnormal. A continuous increase in he-
matocrit with a relatively stable hemoglobin level led to a
steady decline in MCHC over time. A potential change of
5% or greater in MCHC, as noted from day 2 onward, is
also less than desirable. In general, the WBC appeared
stable for the first 3 days. However, the degree of change
in the WBC of specimens with a normal or high count
observed throughout the study may be considered ac-
ceptable for clinical utility. In contrast, the changes in the
WBC of leukopenic specimens, as observed from day 5
onward in particular, are less than desirable. Like the
Automated CBC and Differential Result Changes—Gulati et al 339
Figure 2. Subcategorization of changes ob-
served in (A) white blood cell count (WBC)
and (B) platelet count (PLT) on storage of
specimens at room temperature, based on the
initial (day 0) result. Mean (62 SDs) percent
change from the value on day 0 and the 95%
confidence intervals are plotted against time
in days after collection of specimen. The
number of specimens is indicated on top of
the 95% confidence interval bars for each
day. Data for low WBC on day 7 and for high
PLT on days 6 and 7 were excluded due to
inadequate number of specimens. PLT (Nor-
mala) indicates normal range platelet data af-
ter excluding 2 specimens that revealed a
drop in platelet count associated with platelet
clumping.

Table 4. Percent Changes or Differences in Automated Differential Results Induced by Storage of Blood at Room
Temperature*
Day 0 Day 1 Day 2 Day 3 Day 4 Day 5 Day 6 Day 7
Parameter (n 5 40) (n 5 40) (n 5 39) (n 5 37) (n 5 15†) (n 5 24) (n 5 16) (n 5 12)
Neutrophils, % 0.0 21.1 (12.6) 20.6 (26.8) 5.6 (32.9) 21.4 (33.4) 12.3 (39.2) 10.5 (40.2) 1.1 (24.3)
Lymphocytes, % 0.0 34.8 (150.6) 39.3 (121.5) 97.8 (440.1) 62.2 (251.3) 29.1 (93.9) 65.4 (137.2) 73.1 (104.9)
Monocytes, % 0.0 220.7 (51.4) 0.4 (203.6) 256.4 (47.7) 285.4 (14.6) 250.6 (164.7) 265.6 (73.4) 278.5 (23.8)
Eosinophils, %‡ 0.0 0.2 (1.1) 1.6 (8.3) 2.0 (12.9) 4.0 (13.7) 7.4 (16.5) 4.7 (7.3) 7.9 (9.7)
Basophils, %‡ 0.0 0.1 (0.7) 20.1 (0.5) 20.1 (0.5) 20.2 (0.3) 20.1 (0.2) 0.0 (0.3) 0.0 (0.4)
Neutrophils, No. 0.0 20.4 (11.2) 3.5 (21.3) 6.7 (33.3) 16.0 (31.4) 20.1 (55.7) 24.5 (71.8) 4.8 (40.2)
Lymphocytes, No. 0.0 12.6 (32.0) 38.3 (110.2) 27.6 (58.8) 3.3 (61.2) 45.2 (93.9) 73.9 (140.7) 81.3 (89.6)
Monocytes,
No. 3 103/mL‡ 0.0 20.2 (0.3) 20.1 (1.4) 20.5 (0.4) 20.5 (0.3) 20.6 (0.5) 20.6 (0.6) 20.6 (0.6)
Eosinophils,
No. 3 103/mL‡ 0.0 0.0 (0.2) 0.0 (0.3) 0.1 (0.9) 0.1 (0.3) 0.3 (0.7) 0.3 (0.4) 0.6 (0.7)
Basophils,
No. 3 103/mL‡ 0.0 0.0 (0.2) 0.0 (0.2) 0.0 (0.2) 0.0 (0.0) 0.0 (0.0) 0.0 (0.0) 0.0 (0.0)
* Data are presented as mean (SD).
† Total number of specimens on day 4 is lower than that on day 5 because a run on the Coulter Gen.S was inadvertently missed for a batch of
specimens on day 4.
‡ Absolute difference.

340 Arch Pathol Lab Med—Vol 126, March 2002 Automated CBC and Differential Result Changes—Gulati et al

WBC, the platelet count in general appeared stable for the
first 4 days. However, the degree of change in the platelet
count observed throughout the study in specimens with
the platelet count within or above the normal range may
be considered acceptable for clinical utility. A less than
desirable degree of change was observed only in throm-
bocytopenic specimens, particularly from day 5 onward.
The MPV behaved like the MCV for the initial 5 days,
showing a continuous increase, with a relatively faster rate
of change during the first 2 days when compared with
that during the subsequent 3 days. A mean percent change
in the MPV of 10 or greater, as noted from day 2 onward,
is also less than desirable.
Our observations of changes in CBC results induced by
Arch Pathol Lab Med—Vol 126, March 2002
Figure 3. Changes observed in automated
differential results on storage of blood at
room temperature. Mean (62 SDs) percent
change or difference, as indicated, from the
value on day 0 and the 95% confidence in-
tervals are plotted against time in days after
collection of specimen. The number of spec-
imens is indicated on top of the 95% confi-
dence interval bars for each day.
storage of blood at room temperature agree with those of
Cohle and associates5 published 2 decades ago. This agree-
ment is noted despite the difference in the total number
(12 to 40 vs 10) and types of specimens (normal plus ab-
normal vs only normal) used in the 2 studies. The auto-
mated analyzer used by Cohle et al5 to obtain CBC results
was Coulter S-Plus, also an impedance technology–based
cell counter. These findings suggest that clinically usable
results may be obtained for some CBC parameters from
blood specimens stored at room temperature for up to 7
days. Specifically, the RBC, hemoglobin, and MCH were
stable for the maximum study period of 7 days. The WBC
and platelet count were fairly stable for 4 days or even
longer (up to 7 days) if the counts were within or above
Automated CBC and Differential Result Changes—Gulati et al 341
the normal range. Relatively wide fluctuations (large SDs)
in the WBC and platelet count of specimens with counts
below the normal range are understandable and attribut-
able, at least partly, to lower degree of precision known to
be associated with low counts when compared with nor-
mal or high counts by automated or manual methods. Ad-
ditionally, the small number of specimens from day 4 on-
ward could have contributed to wider fluctuations noted
during the same period for specimens with counts below
or within the normal range. A progressive increase in
MPV, MCV, hematocrit, and RDW and a decrease in
MCHC from day 2 onward make the results of these pa-
rameters suspect in terms of clinical utility, especially in
cases where the results of these parameters are borderline
normal or abnormal.
Storage of blood at room temperature caused changes
in virtually all of the parameters of automated differential.
Beginning on day 1, 2, or 3, the relative percentages and
absolute numbers of neutrophils, lymphocytes, and eosin-
ophils tended to increase, whereas the opposite was true
for the relative percentage and absolute number of mono-
cytes. The increase in the percentage of neutrophils began
on day 3, number of neutrophils on day 2, percentage and
number of lymphocytes on day 1, percentage of eosino-
phils on day 1, and number of eosinophils on day 3. The
percentage and number of monocytes trended downward
from day 1 onward. The relative percentage and absolute
number of basophils, although difficult to reliably evaluate
because they represented a very small fraction, if any, of
total leukocytes, trended either downward or showed no
appreciable change, particularly in the absolute number
throughout the study period. These changes in white
blood cell differential are most likely the sum effect of the
loss of individual cell characteristics specifically measured
by the analyzer and the cellular degeneration that is
known to occur as the cell ages.
An increase in lymphocytes and a decrease in mono-
cytes after 24 and 48 hours of storage of blood at room
temperature have also been reported previously by Warn-
er and Reardon,2 who analyzed 25 specimens from
healthy subjects using Coulter STKS, which, like the Coul-
ter Gen.S, uses VCS technology for the differential count.
Compared with an appreciable decrease in neutrophils
noted at the same period by these investigators, we ob-
served only a small or rather negligible decrease in per-
centage of neutrophils on days 1 and 2 and in number of
neutrophils on day 1, beyond which both the percentage
and number of neutrophils increased, although to a vari-
able degree, for the remainder of the study period. Unlike
our observations of an increase in the percentage and
number of eosinophils and a decrease in the percentage
and number of basophils, Warner and Reardon2 noted a
decrease in the percentage of eosinophils and an increase
in the percentage of basophils after 24 and 48 hours of
storage at room temperature. Differences in the sample
size and sample type between the 2 studies may at least
partly account for the different findings. The observations
on changes in neutrophils, lymphocytes, and monocytes
342 Arch Pathol Lab Med—Vol 126, March 2002
after 1 day of storage at room temperature are also cor-
roborated by the published reports of Wood et al,6 who
analyzed 21 specimens from healthy volunteers and 113
patient specimens using Cell Dyn-3500, which performs
differential analysis by measuring laser light scattering
properties of cells at various angles.
To the best of our knowledge, there are no other pub-
lished reports in the English language pertaining to the
study of changes in the automated differential induced by
prolonged storage of blood at room temperature. Based
on the findings of this study and the cited published re-
ports, it can be surmised that even after only 24 hours a
specimen may yield unreliable differential results when
using the VCS technology. Storage of blood at 48C has
been shown to prolong the specimen stability by several
days for many CBC parameters3,4,6,7 and by a couple of
days for some differential parameters.2,6 Refrigeration is
not a solution, however, for specimens that arrive at the
laboratory after being stored at room temperature for a
few days.
CONCLUSION
Although it is preferable to perform a CBC and differ-
ential on a blood specimen as soon as possible after col-
lection, our study suggests that clinically reliable results
may be obtained for some CBC parameters, but not for
the differential, from specimens older than 1 day, when
analyzed on the Coulter Gen.S. Specifically, hemoglobin,
RBC, and MCH are stable for at least 7 days, WBC for at
least 3 days, and platelets for at least 4 days of storage at
room temperature. Based on these findings, laboratories
using VCS technology for CBC and differential may de-
cide to accept specimens older than 24 hours for analysis
and report only the results of the stable CBC parameters.
Under these circumstances, a comment such as ‘‘unable to
obtain reliable results due to the age of the specimen’’ or
‘‘specimen too old to obtain reliable results’’ could replace
the results of unstable parameters. Alternatively, one may
choose to report the results of all CBC parameters, but
with a comment such as ‘‘specimen pp days old, results
may be affected’’ appended to the result(s) of one or more
unstable parameters.
We are grateful to the hematology laboratory staff for technical
help, Medical Media Graphics staff for preparing the illustrations,
and John O’Connor, PhD, of Department of Health Policy for
helpful hints in data analysis.
References
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November 1996.
2. Warner BA, Reardon DM. A field evaluation of the Coulter-STKS. Am J Clin
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3. Brittin GM, Brecher G, Johnson CA, Elashoff RM. Stability of blood in com-
monly used anticoagulants. Am J Clin Pathol. 1969;52:690–694.
4. Lampasso JA. Changes in hematologic values induced by storage of ethy-
lenediaminetetra-acetate human blood for varying periods of time. Am J Clin
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Automated CBC and Differential Result Changes—Gulati et al