CBC’s Short Term “Response” Strategy (18 Months: March 2010 – September 2011)
Taking The Fear Out of Abnormal CBC’s Problems of ...c.ymcdn.com/sites/ · Abnormal CBC’s...
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Taking The Fear Out of Abnormal CBC’s
Problems of Production, Destruction or loss
Joanne Eddington, MN, FNP, AOCN
Providence Oncology and Hematology Care Clinic - Eastside
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Blood Cell Abnormalities
Abnormalities of production
Parts? Factory?
Abnormalities related to loss
Bleeding? Sequestration?
Abnormalities related to destruction
Autoimmune/Idiopathic?
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Variables to focus on
Hgb and Hct
MCV
RBC distribution width (RDW)
Platelets
WBC with differential
Patients baseline, differences based on sex and race.
If abnormality exists out of context, repeat the test.
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Coulter counter
Counts circulating blood cells by electrical pulse
The height of the pulse indicates cell volume
Newer counters give multimodal assessment of cell size and content which is the differential.
5 part differential includes neutrophils, lymphocytes, monocytes, eosinophils and basophils
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Stick The Tube In The Machine- And Let IT Do Magic
Automated Hematology Analyzer
2 CHAMBERS In one chamber, the red cells are counted. The detecter is set to count merely the cells the size limits of Red Blood Cells. In the other chamber, the blood is put into a solution that lyses the red blood cell leaving merely WBC and platelets intact.
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Approaches to evaluation
History
Physical exam
Review of differential and peripheral smear as appropriate
Additional tests as appropriate
Depending on results, Hematology referral.
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Platelet Abnormalities
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Thrombocytopenia
Definition: Platelet count < 150,00
Asymptomatic Thrombocytopenia Found on routine CBC
Symptomatic Thrombocytopenia Bleeding, bruising or petechiae
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Thrombocytopenia
Decreased platelet production Viral infection, HIV, Hep C, Parvovirus Leukemia, Vitamin deficiency
Increased Platelet Destruction Drugs: Heparin, Valproic acid Autoimmune destruction ( TTP, ITP, Lupus) DIC
Platelet loss / Psuedothrombocytopenia Platelet clumping (EDTA induced), Pregnancy Splenic sequestration
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Critical Values
Surgeons will generally consider platelet number to be adequate if >50,000
Spontaneous bleeding does not occur unless platelet count is < 20,000
Transfuse platelets if <10,000 or spontaneous bleeding
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Laboratory evaluation for Thrombocytopenia
CBC with manual differential, PT/PTT and review of Peripheral smear
Evaluate for drug induced thrombocytopenia and hypersplenism Abdominal ultrasound
Rule out HIV infection, lymphoproliferative disorder and autoimmune disease. HIV testing, ANA and SPEP
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Points to remember…….
TTP/hemolytic uremic syndrome need urgent therapy.
Idiopathic thrombocytopenic purpura is a diagnosis of exclusion.
ITP: less likely to bleed spontaneously as platelets are often young and vigorous!
Bone Marrow biopsy or platelet antibody tests are not indicated in most work-ups of ITP.
It is appropriate to initiate work-up but most situations should be referred to Hematology.
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Thrombocytosis
Marrow over production
Myeloproliferative disorder
Can be a result of something else going on (Reactive Thrombocytosis)
Seen in iron deficiency
Seen in post surgical patients
Seen in infection
Seen in trauma
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Thrombocytosis
Defined as >450,000 but evaluation is not necessarily indicated unless near 600,000 Primary Thrombocytosis versus Reactive Thrombocytosis
Elevated platelet count can be due to a myeloid malignancy or myeloproliferative process
Elevated platelet count can be due to a secondary process such as:
Iron Deficiency Anemia Infection/Inflammation/Tissue Damage Hemolysis Nonmyeloid malignancy Splenectomy
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Thrombocytosis continued
The difference between primary thrombocytosis and reactive thrombocytosis is clinically relevant because primary thrombocytosis is associated with increased risk of thrombohemorragic complications and reactive thrombocytosis is not.
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Clinical evaluation of Thrombocytosis
Patient History
Old medical record will determine if a new or longstanding problem
Splenectomy? Chronic thrombocytosis in patients with a spleen is highly suggestive of primary thrombocytosis.
Chronic thrombocytosis in patient without a spleen is a benign condition.
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Laboratory evaluation
CBC
Increased HGB, MCV or WBC or immature WBC, suggests Primary Thrombocytosis/Myeloproliferative disorder
Serum Ferritin
Rule out iron deficiency
C-Reactive Protein
Elevation indicates an inflammatory cause
Normal levels are seen in a marrow disorder
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If no cause can be found for a reactive process, refer……….
Hematology evaluation will likely include:
JAK 2 testing
Bone Marrow biopsy
Bcr/Abl
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Primary Thrombocytosis
Myeloproliferative disorders
Essential Thrombocytosis
Polycythemia Vera
Primary Myelofibrosis
Myeloid Malignancies
MDS
CML
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White Blood Cell Abnormalities
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Leukopenia/Neutropenia
Leukopenia refers to a low total WBC
Granulocytopenia refers to a decrease in circulating neutrophils, eosinophils and basophils
Neutropenia refers to a decrease in circulating neutrophils
ANC or absolute neutrophil count =
Total WBC x percent (polys + bands) / 100
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Points to remember
Patients with moderate to severe neutropenia will not demonstrate classic signs of infection other than fever.
Ethnic variations: African Americans, Yemenite Jews, Ethiopians and certain Arabs normally have a slightly lower WBC and ANC. Benign Ethnic Neutropenia (ANC not <500)
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Acquired vs congenital Neutropenia
Congenital neutropenias are rare
Acquired causes: Drugs or infections (virus, sepsis) are more common
Immune disorders: HIV, Chronic Idiopathic Neutropenia
Leukemia or other hematologic malignancies rarely present with isolated neutropenia
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Lymphopenia
Often caused by immune suppressive drugs including steroids and anti-lymphocyte monoclonal antibodies
HIV
Critical illness
Connective tissue diseases
Lymphopenia seen in elderly patients, where it is usually of no clinical significance. No further investigation is advised in an elderly patient with a lymphocyte count >0.5×109/L in the absence of any concerning symptoms
Persistent lymphopenia that remains stable over a six month period and in the absence of symptoms, clinical findings, or abnormal results from investigations does not require further investigation
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Diagnostic Approach
If leukopenia, neutropenia or granulocytopenia is identified along with other blood abnormalities such as normocytic anemia and/or thrombocytopenia, a peripheral smear and an immediate referral to a hematologist for a bone marrow biopsy should be done.
Mild neutropenia without recurrent infections or protracted infection can be observed.
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Diagnostic Approach cont’
If observation is appropriate ANC should be checked at least 2-3 times per week for 6-8 weeks.
If neutropenia persists, refer to Hematologist for a bone marrow biopsy and further evaluation.
Moderate to severe neutropenia with infection should be referred directly to Hematologist for bone marrow biopsy and further evaluation.
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Leukocytosis
First step in evaluation is to determine which WBC type is increased.
The increase maybe secondary to immature precursors (blasts) or an expansion of mature leukocytes such as granulocytes, lymphocytes, monocytes.
Manual differential and review of peripheral smear will help classify and rule out acute leukemia.
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Leukocytosis
Total WBC > 11,000
Leukocytosis commonly is due to an increase in the number of circulating neutrophils
Leukocytosis can also be due to an increase in other white blood cell such as lymphocytes, eosinophils, monocytes or rarely basophils.
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Causes to consider:
Normal variation
By definition 2.5% of the population will be greater than 2 SD above the mean
Blood sampling problem
Platelet clumping
Infection or inflammation
Total WBC + CRP + Neutrophils
Drugs
Bone Marrow disorder
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Specific differential abnormalities
Neutrophilic leukocytosis: infection, stress, smoking, pregnancy, PV and CML
Lymphocytic leukocytosis: Infections such as mono, ALL, CLL, NHL
Monocytic leukocytosis: Acute bacterial infections, TB, AML and CML/MDS
Eosinophilic or basophilic leukocytosis: paracytic infections, allergic reactions, solid tumors, forms of chronic and acute leukemia's (HES)
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Red Blood Cell Abnormalities
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Anemia's
Various definitions (hemoglobin and hematocrit levels)
< 12 in women and < 14 in men
Production problems, destruction problems or loss
Classification:
Normocytic, Macrocytic, Microcytic
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Anemia Parameters
Print out from out from machine RBC counted (coulter) HB measured (light abs) MCV – from size distribution
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Initial questions to ask:
Is the patient bleeding?
Is there evidence for RBC destruction/hemolysis?
Is the bone marrow suppressed?
Is there iron deficiency? If so why?
Is there B12 or folate deficiency? If so why?
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Initial test to order
Complete Blood Count with differential
Iron studies with ferritin
B 12 and Folate
Reticulocyte count
CMP (creatinine, total protein, LFT’s)
TSH
Additional studies depending on these results.
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What Test Tells Production v Destruction? Reticulocytes
Reticulocytes are immature red blood cells, typically composing about 1% of the red cells
Reticulocytes mature in bone marrow and then circulate for about a day in the blood stream
They are called reticulocytes because of a reticular (mesh-like) network of ribosomal RNA that becomes visible under a microscope with certain stains such as new methylene blue
This test must be ordered separately Modern instruments can automate
the process
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Microcytic Anemia
Definition: MCV < 80
Caused by:
Iron deficiency
Thalassemia
Chronic disease
Serum ferritin should be the first test to check as part of initial work-up.
Iron deficiency is unlikely in the presence of persistently normal or elevated serum ferritin.
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What do you see? Microcytosis and increase in RDW
MCV= 72 Classic Iron deficiency anemia
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Iron Deficiency Anemia (IDA)
Most common form of anemia
Should be ruled out initially in every anemia workup.
Can see iron deficiency combined with other types of anemia
# 1 cause of iron deficiency is bleeding
The cause of bleeding should be sought in every case.
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IDA continued
Always trial oral iron unless patient has documented absorption problem
Parenteral iron can replenish iron stores in 1 dose. But not risk free.
Standard of care is to replace iron stores. Don’t transfuse.
Note- it will take 1-2 mos for HB to rise, be patient
If patient is bleeding, stop the bleeding first as they will not retain the iron you give them!
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Thalassemia
This should be considered if patient is microcytic but not iron deficient.
Patient can have Thalassemia and IDA. Iron deficiency must be corrected before testing for
Thalassemia. History is very important in identifying Thalassemia Don’t give iron unless iron deficient. Use Hematologist to interpret Hgb electrophoresis
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Microcytic anemia of chronic disease
Otherwise known as anemia of inflammation
These are anemias of Chronic Inflammatory diseases, like RA. THIS IS NOT CHF, HTN, DM which are chronic diseases, not characterized by inflammation
Usually iron studies demonstrate:
Low serum iron, low total iron binding capacity and increased serum ferritin.
However, ferritin could be elevated by inflammatory process itself.
Bone marrow biopsy maybe necessary to rule out iron deficiency.
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Macrocytic Anemia
Definition: MCV > 100
Caused by:
B12 or folate deficiency (consider MMA levels)
Hypothyroidism
Hemolysis (consider LDH and Direct Coombs)
Myelodysplastic syndrome
Alcoholism, liver disease
Medications
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Macrocytic anemia continued
Once the cause is determined, appropriate treatment can then be administered as indicated.
Hematology evaluation is indicated if MDS or hemolytic anemia is suspected.
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Normocytic Anemia
MCV 80 -100
Caused by:
Bleeding
Renal insufficiency
Hemolysis (valve, TTP/HUS, DIC, autoimmune, etc.)
Nutritional deficiency (yes…iron, B12 and folate)
Bone marrow disorders
Anemia of Chronic Inflammation (here too- both micro and normo cytic )
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Normocytic anemia
If the work-up excludes bleeding, nutritional deficits, renal insufficiency, hemolysis, then the anemia is related to chronic disease or a primary bone marrow disorder.
Evaluation for hemolysis:
Schistocytes or spherocytes on smear
Haptoglobin, Lactate dehydrogenase (LDH), Direct coombs, indirect bilirubin, and reticulocyte count. Consider drug-induced.
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Polycythemia
Suspected when Hgb and Hct are elevated.
Primary Polycythemia (Polycythemia rubra vera; PV)
Is a myeloproliferative disorder of the bone marrow.
Secondary Polycythemia
Caused by increased EPO levels due to hypoxia or an EPO producing tumor.
Relative Polycythemia
Caused by a decreased plasma volume increasing Hgb, Hct and RBC count.
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Laboratory evaluation of Polycythemia
Carboxyhemoglobin levels
Elevated in smokers
Erythropoietin levels
Elevated Suggests erythropoietin producing tumor
Low is characteristic of Polycythemia Vera
JAK 2 testing
Diagnostic for Myeloproliferative Disorder and Polycythemia Rubra Vera.
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In summary
If the patient feels sick and has abnormal blood counts…..be worried and refer.
If the patient has more than 1cell line abnormal even if they don’t feel bad….be worried and refer.
If the laboratory result does not fit with the clinical situation, recheck. Consider running CBC in heparin instead of EDTA.
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In Summary continued
If the patient has mildly low abnormalities and feels fine…..consider watching and waiting.
Pay attention to the work-ups that your friendly hematologist does on your patients. This will improve your initial work-up overtime.