Erythrocyte Sedimentation Rate
(ESR)
1
alkafeel.edu.iq info@alkafeel.edu.iq Tuesday, August 24, 2021
Erythrocyte Sedimentation
Rate
ESR is the rate at which erythrocytes settle out of anticoagulant
mixed blood in one hour, so its unit mm/hour. It is measuring the
sedimentation of red cells in their native plasma, and it indicates
the suspension stability of erythrocytes.
ESR reflects mainly changes in plasma proteins concentration pattern.
It may be used to detect a wide range of organic diseases.
It also provides a mean of monitoring progress and response to treatment in chronic diseases.
It most useful for diagnosis of temporal arteries, rheumatoid arthritis and polymyalgia
rheumatic.
2
alkafeel.edu.iq info@alkafeel.edu.iq Tuesday, August 24, 2021
Erythrocyte Sedimentation
Rate
Sedimentation occurs when the erythrocytes clump or aggregate together in rouleaux
formation, increased rouleaux formation contributes to high ESR.
These changes are related to alteration in the plasma proteins due to inflammatory and
necrotic processes.
Plasma proteins, especially fibrinogen, adhere to the red cell membranes and neutralize the
surface negative charges, promoting cell
adherence and rouleaux formation, which makes
them heavier and more likely to fall rapidly when
placed in a special vertical tube.
3
alkafeel.edu.iq info@alkafeel.edu.iq Tuesday, August 24, 2021
Erythrocyte Sedimentation
Rate Factors that effect on ESR
RBC ESR
Plasma ESR
Rouleaux ESR
Fibrinogen ESR
Immunoglobulin
Albumin ESR
4
alkafeel.edu.iq info@alkafeel.edu.iq Tuesday, August 24, 2021
Erythrocyte Sedimentation
Rate
There are two main methods for performing the ESR:
Westergren method
Winthrob’s method
Westergren Method
It adopted as approved method.
The sample, either the venous blood directly or EDTA mixed blood, is diluted accurately in
the proportion of 1 volume of Tri-sodium citrate to 4 volumes of blood.
The test should be carried out on the diluted sample within 4 h of collecting the blood.
Delay of up to 6 h is permissible provided that the blood is kept at 4 C°.
5
alkafeel.edu.iq info@alkafeel.edu.iq Tuesday, August 24, 2021
Erythrocyte Sedimentation
Rate Principle:
The blood collected into an anticoagulant is placed in a long graduated tube held in a vertical position
for one hour at room temperature (18-25 C°).
The erythrocytes settle to the bottom, leaving a layer of plasma above. The height of the plasma
column indicates the sedimentation rate of ESR.
The sedimentation occurs in three stages:
The primary stage: about 10 min during which the rouleaux formation and aggregation occurs.
The second stage: approximately 40 min in which the aggregation sinking and sedimentation occurs
at a constant speed.
The final stage: about 10 min during which aggregation cells pack at the bottom of the tube.
6
alkafeel.edu.iq info@alkafeel.edu.iq Tuesday, August 24, 2021
Erythrocyte Sedimentation
Rate 3.8% Tri-sodium citrate, as an anticoagulant, and dilute the blood.
Reagent:
Tools:
Westergren tube: is a straight glass or transparent plastic tube, 300 mm (30 cm) in length
and more than 2.5 mm in diameter. A scale graduated from 0-200 mm only.
ESR rack: especially rack with adjustable leveling screws for holding the sedimentation
tubes in vertical position.
Pipette
Timer
7
alkafeel.edu.iq info@alkafeel.edu.iq Tuesday, August 24, 2021
Erythrocyte Sedimentation
Rate Procedure:
1. The proportion volume of mixing one volume of sodium citrate to four volume of blood
(i.e. 1.6 ml blood + 0.4 ml sodium citrate) assembly in tube.
2. the mixed blood sample draw up into the clean, dry Westergren tube to the zero mark by
means a mechanical device; mouth suction should never be used.
8
alkafeel.edu.iq info@alkafeel.edu.iq Tuesday, August 24, 2021
Erythrocyte Sedimentation
Rate
3. Place the Westergren tube in ESR rack in strictly vertical position at room temperature for
one hour, free from vibrations and not exposed to direct sunlight.
4. Read the height of the clear plasma above the upper limit of the column of sedimenting cells
(number of the limit between plasma and precipitate blood). This number represents ESR
value.
9
alkafeel.edu.iq info@alkafeel.edu.iq Tuesday, August 24, 2021
Erythrocyte Sedimentation
Rate Westergren Method
Modified
used for determining the ESR of whole blood in 30 minutes
using ESR-Vacuum tubes (disposable black Westergren tube) and ESR fast detector (ESR
rack).
Also called fast ESR method,
with the same principle as the Westergren method.
10
alkafeel.edu.iq info@alkafeel.edu.iq Tuesday, August 24, 2021
Erythrocyte Sedimentation
Rate Procedure:
1) Add the blood up to the indicated fill line of the ESR-Vacuum tube (8 x 120 mm) that
prefilled with 3.2% sodium citrate.
2) Immediately invert the tube at 180 degrees for 6-8 times to ensure thorough mixing, which
will avoid hemolysis, clotting or blood bubble.
3) Adjust feet and levelling bubble on ESR rack to ensure the tube is maintained in a vertical
position during testing.
4) Place the ESR-Vacuum tube containing blood sample onto the detector at room temperature
for 30 min, away from vibrations and exposed to direct sunlight.
11
alkafeel.edu.iq info@alkafeel.edu.iq Tuesday, August 24, 2021
Erythrocyte Sedimentation
Rate Procedure:
5) Set the start of the plasma column in ESR tube to the (0) mark of ESR rack, then read the
height of the plasma above the column of sedimenting cells (number of the limit between
plasma and precipitate blood).
This number represents ESR value and is expressed as X mm/h.
12
alkafeel.edu.iq info@alkafeel.edu.iq Tuesday, August 24, 2021
Erythrocyte Sedimentation
:Errors
Rate
Wet, dirty syringe or pipette.
Incorrect dilution or concentration of sodium Citrate.
Insufficient mixing.
Partial clotting.
Delaying setting beyond 4 hours.
Air bubbles and froth formation.
High temperature: sedimentation is normally accelerated as the temperature increases.
Non-vertical ESR pipette position.
Vibration the sample. 13
alkafeel.edu.iq info@alkafeel.edu.iq Tuesday, August 24, 2021
Erythrocyte Sedimentation
Rate
Reference values by Westergren’s method
Newborn: 0-4 mm/h.
Children: 0-10 mm/h.
Adult men: 0-15 mm/h (over age 50 years: 0-20 mm/h)
Adult women: 0-20 mm/h (over age 50 years: 0-30 mm/h)
14
alkafeel.edu.iq info@alkafeel.edu.iq Tuesday, August 24, 2021
Erythrocyte Sedimentation
Rate
The ESR increased conditions:
1. Increased of fibrinogen, immunoglobulin, C-reactive protein, high cholesterol.
2. Menstruation and Pregnancy after 12 weeks, this is due to the physiological effect of
hemodilution.
3. Drugs like heparin, oral contraceptives.
4. Anemia, due to the hemodilution.
5. Macrocytosis.
6. Tissues injury and burns.
7. Chronic diseases e.g. Tuberculosis (T.B.), rheumatoid fever, malignancies.
15
alkafeel.edu.iq info@alkafeel.edu.iq Tuesday, August 24, 2021
Erythrocyte Sedimentation
Rate
The ESR decreased conditions:
1. Abnormal RBCs like sickle cells, spherocytes, microcytes.
2. Drugs like steroid, anti-inflammatory medications, high dose aspirin.
3. High blood sugar.
4. Congestive heart failure.
5. High albumin level.
6. Hyperviscosity.
7. Leukemia, Polycythemia.
16
alkafeel.edu.iq info@alkafeel.edu.iq Tuesday, August 24, 2021
ANY
?QUESTIONS
17
alkafeel.edu.iq info@alkafeel.edu.iq Tuesday, August 24, 2021
