Complete blood count
Complete blood count | |
---|---|
Synonyms | Complete blood cell count,[1] full blood count (FBC),[2] full blood cell count,[3] full blood examination (FBE),[2] hemogram[4] |
MeSH | D001772 |
MedlinePlus | 003642 |
LOINC | Codes for CBC, e.g., 57021-8 |
HCPCS-L2 | G0306 |
A complete blood count (CBC), also known as a full blood count (FBC), is a set of
The CBC is often carried out as part of a medical assessment and can be used to monitor health or diagnose diseases. The results are interpreted by comparing them to
The CBC is usually performed by an automated hematology analyzer, which counts cells and collects information on their size and structure. The concentration of hemoglobin is measured, and the red blood cell indices are calculated from measurements of red blood cells and hemoglobin. Manual tests can be used to independently confirm abnormal results. Approximately 10–25% of samples require a manual blood smear review,[5] in which the blood is stained and viewed under a microscope to verify that the analyzer results are consistent with the appearance of the cells and to look for abnormalities. The hematocrit can be determined manually by centrifuging the sample and measuring the proportion of red blood cells, and in laboratories without access to automated instruments, blood cells are counted under the microscope using a hemocytometer.
In 1852,
Purpose
Blood is composed of a fluid portion, called
The CBC is often used to
The complete blood count has specific applications in many
The complete blood count is an essential tool of
The
Procedure
The sample is collected by drawing blood into a tube containing an
Automated
On board the analyzer, the sample is agitated to evenly distribute the cells, then diluted and partitioned into at least two channels, one of which is used to count red blood cells and platelets, the other to count white blood cells and determine the hemoglobin concentration. Some instruments measure hemoglobin in a separate channel, and additional channels may be used for differential white blood cell counts, reticulocyte counts and specialized measurements of platelets.[46][47][48] The cells are suspended in a fluid stream and their properties are measured as they flow past sensors in a technique known as flow cytometry.[note 3][49][52] Hydrodynamic focusing may be used to isolate individual cells so that more accurate results can be obtained: the diluted sample is injected into a stream of low-pressure fluid, which causes the cells in the sample to line up in single file through laminar flow.[53][54]
To measure the hemoglobin concentration, a
Sensors count and identify the cells in the sample using two main principles:
In light scattering techniques, light from a
Most analyzers directly measure the average size of red blood cells, which is called the
After being treated with reagents, white blood cells form three distinct peaks when their volumes are plotted on a histogram. These peaks correspond roughly to populations of
Most analyzers take less than a minute to run all the tests in the complete blood count.[58] Because analyzers sample and count many individual cells, the results are very precise.[76] However, some abnormal cells may not be identified correctly, requiring manual review of the instrument's results and identification by other means of abnormal cells the instrument could not categorize.[5][77]
Point-of-care testing
Manual
The tests can be performed manually when automated equipment is not available or when the analyzer results indicate that further investigation is needed.
To perform a manual white blood cell differential, the microscopist counts 100 cells on the blood smear and classifies them based on their appearance; sometimes 200 cells are counted.
The hematocrit can performed manually by filling a capillary tube with blood, centrifuging it, and measuring the percentage of the blood that consists of red blood cells.[66] This is useful in some conditions that can cause automated hematocrit results to be incorrect, such as polycythemia (a highly elevated red blood cell count)[66] or severe leukocytosis (a highly elevated white blood cell count, which interferes with red blood cell measurements by causing white blood cells to be counted as red cells).[91]
Red and white blood cells and platelets can be counted using a
Hemoglobin can be measured manually using a
In rural and economically disadvantaged areas, available testing is limited by access to equipment and personnel. At primary care facilities in these regions, testing may be limited to examination of red cell morphology and manual measurement of hemoglobin, while more complex techniques like manual cell counts and differentials, and sometimes automated cell counts, are performed at district laboratories. Regional and provincial hospitals and academic centres typically have access to automated analyzers. Where laboratory facilities are not available, an estimate of hemoglobin concentration can be obtained by placing a drop of blood on a standardized type of absorbent paper and comparing it to a colour scale.[97]
Quality control
Automated analyzers have to be regularly
In addition to analyzing internal quality control samples with known results, laboratories may receive external quality assessment samples from regulatory organizations. While the purpose of internal quality control is to ensure that analyzer results are reproducible within a given laboratory, external quality assessment verifies that results from different laboratories are consistent with each other and with the target values.[103] The expected results for external quality assessment samples are not disclosed to the laboratory.[104] External quality assessment programs have been widely adopted in North America and western Europe,[99] and laboratories are often required to participate in these programs to maintain accreditation.[105] Logistical issues may make it difficult for laboratories in under-resourced areas to implement external quality assessment schemes.[106]
Included tests
The CBC measures the amounts of platelets and red and white blood cells, along with the hemoglobin and hematocrit values. Red blood cell indices—MCV, MCH and MCHC—which describe the size of red blood cells and their hemoglobin content, are reported along with the red blood cell distribution width (RDW), which measures the amount of variation in the sizes of red blood cells. A white blood cell differential, which enumerates the different types of white blood cells, may be performed, and a count of immature red blood cells (reticulocytes) is sometimes included.[4][107]
Red blood cells, hemoglobin, and hematocrit
Analyte | Result | Normal range |
---|---|---|
Red cell count | 5.5 x 1012/L | 4.5–5.7 |
White cell count | 9.8 x 109/L | 4.0–10.0 |
Hemoglobin | 123 g/L | 133–167 |
Hematocrit | 0.42 | 0.35–0.53 |
MCV | 76 fL | 77–98 |
MCH | 22.4 pg | 26–33 |
MCHC | 293 g/L | 330–370 |
RDW | 14.5% | 10.3–15.3 |
Red blood cells deliver
Two other measurements are calculated from the red blood cell count, the hemoglobin concentration, and the hematocrit: the mean corpuscular hemoglobin and the mean corpuscular hemoglobin concentration.[114][115] These parameters describe the hemoglobin content of each red blood cell. The MCH and MCHC can be confusing; in essence the MCH is a measure of the average amount of hemoglobin per red blood cell. The MCHC gives the average proportion of the cell that is hemoglobin. The MCH does not take into account the size of the red blood cells whereas the MCHC does.[116] Collectively, the MCV, MCH, and MCHC are referred to as the red blood cell indices.[114][115] Changes in these indices are visible on the blood smear: red blood cells that are abnormally large or small can be identified by comparison to the sizes of white blood cells, and cells with a low hemoglobin concentration appear pale.[117] Another parameter is calculated from the initial measurements of red blood cells: the red blood cell distribution width or RDW, which reflects the degree of variation in the cells' size.[118]
An abnormally low hemoglobin, hematocrit, or red blood cell count indicates anemia.
An increased number of red blood cells, leading to an increase in the hemoglobin and hematocrit,
Evaluation of red blood cell indices is helpful in determining the cause of anemia. If the MCV is low, the anemia is termed
Microcytic anemia is typically associated with iron deficiency, thalassemia, and
A low RDW has no clinical significance, but an elevated RDW represents increased variation in red blood cell size, a condition known as
White blood cells
|
|
White blood cells defend against infections and are involved in the
In the white blood cell differential, the different types of white blood cells are identified and counted. The results are reported as a percentage and as an absolute number per unit volume. Five types of white blood cells—
Differential results are useful in diagnosing and monitoring many medical conditions. For example, an elevated neutrophil count (
An increased number of
Platelets
Platelets play an essential role in clotting. When the wall of a
The mean platelet volume (MPV) measures the average size of platelets in femtolitres. It can aid in determining the cause of thrombocytopenia; an elevated MPV may occur when young platelets are released into the bloodstream to compensate for increased destruction of platelets, while decreased production of platelets due to dysfunction of the bone marrow can result in a low MPV. The MPV is also useful for differentiating between congenital diseases that cause thrombocytopenia.[118][166] The immature platelet fraction (IPF) or reticulated platelet count is reported by some analyzers and provides information about the rate of platelet production by measuring the number of immature platelets in the blood.[167]
Other tests
Reticulocyte count
Reticulocytes are immature red blood cells, which, unlike the mature cells, contain RNA. A reticulocyte count is sometimes performed as part of a complete blood count, usually to investigate the cause of a person's anemia or evaluate their response to treatment. Anemia with a high reticulocyte count can indicate that the bone marrow is producing red blood cells at a higher rate to compensate for blood loss or hemolysis,[74] while anemia with a low reticulocyte count may suggest that the person has a condition that reduces the body's ability to produce red blood cells.[168] When people with nutritional anemia are given nutrient supplementation, an increase in the reticulocyte count indicates that their body is responding to the treatment by producing more red blood cells.[169] Hematology analyzers perform reticulocyte counts by staining red blood cells with a dye that binds to RNA and measuring the number of reticulocytes through light scattering or fluorescence analysis. The test can be performed manually by staining the blood with new methylene blue and counting the percentage of red blood cells containing RNA under the microscope. The reticulocyte count is expressed as an absolute number[168] or as a percentage of red blood cells.[170]
Some instruments measure the average amount of hemoglobin in each reticulocyte; a parameter that has been studied as an indicator of iron deficiency in people who have conditions that interfere with standard tests.
Nucleated red blood cells
During their formation in bone marrow, and in the liver and spleen in fetuses,[173] red blood cells contain a cell nucleus, which is usually absent in the mature cells that circulate in the bloodstream. Nucleated red blood cells are normal in newborn babies,[174] but when detected in children and adults, they indicate an increased demand for red blood cells, which can be caused by bleeding, some cancers and anemia.[118] Most analyzers can detect these cells as part of the differential cell count. High numbers of nucleated red cells can cause a falsely high white cell count, which will require adjusting.[175]
Other parameters
Advanced hematology analyzers generate novel measurements of blood cells which have shown diagnostic significance in research studies but have not yet found widespread clinical use.
Reference ranges
Test | Units | Adult | Pediatric
(4–7 years old) |
Neonate
(0–1 days old) |
---|---|---|---|---|
WBC | × 109/L | 3.6–10.6 | 5.0–17.0 | 9.0–37.0 |
RBC | × 1012/L |
|
4.00–5.20 | 4.10–6.10 |
HGB | g/L |
|
102–152 | 165–215 |
HCT | L/L |
|
0.36–0.46 | 0.48–0.68 |
MCV | fL | 80–100 | 78–94 | 95–125 |
MCH | pg | 26–34 | 23–31 | 30–42 |
MCHC | g/L | 320–360 | 320–360 | 300–340 |
RDW | % | 11.5–14.5 | 11.5–14.5 | elevated[note 6] |
PLT | × 109/L | 150–450 | 150–450 | 150–450 |
Neutrophils | × 109/L | 1.7–7.5 | 1.5–11.0 | 3.7–30.0 |
Lymphocytes | × 109/L | 1.0–3.2 | 1.5–11.1 | 1.6–14.1 |
Monocytes | × 109/L | 0.1–1.3 | 0.1–1.9 | 0.1–4.4 |
Eosinophils | × 109/L | 0.0–0.3 | 0.0–0.7 | 0.0–1.5 |
Basophils | × 109/L | 0.0–0.2 | 0.0–0.3 | 0.0–0.7 |
The complete blood count is interpreted by comparing the output to reference ranges, which represent the results found in 95% of apparently healthy people.[35] Based on a statistical normal distribution, the tested samples' ranges vary with sex and age.[179]
On average, adult females have lower hemoglobin, hematocrit, and red blood cell count values than males; the difference lessens, but is still present, after menopause.[180] CBC results for children and newborn babies differ from those of adults. Newborns' hemoglobin, hematocrit, and red blood cell count are extremely high to compensate for low oxygen levels in the womb and the high proportion of fetal hemoglobin, which is less effective at delivering oxygen to tissues than mature forms of hemoglobin, inside their red blood cells.[181][182] The MCV is also increased, and the white blood cell count is elevated with a preponderance of neutrophils.[181][183] The red blood cell count and related values begin to decline shortly after birth, reaching their lowest point at about two months of age and increasing thereafter.[184][185] The red blood cells of older infants and children are smaller, with a lower MCH, than those of adults. In the pediatric white blood cell differential, lymphocytes often outnumber neutrophils, while in adults neutrophils predominate.[181]
Other differences between populations may affect the reference ranges: for example, people living at higher altitudes have higher hemoglobin, hematocrit, and RBC results, and people of African heritage have lower white blood cell counts on average.[186] The type of analyzer used to run the CBC affects the reference ranges as well. Reference ranges are therefore established by individual laboratories based on their own patient populations and equipment.[187][188]
Limitations
Some medical conditions or problems with the blood sample may produce inaccurate results. If the sample is visibly clotted, which can be caused by poor phlebotomy technique, it is unsuitable for testing, because the platelet count will be falsely decreased and other results may be abnormal.[189][190] Samples stored at room temperature for several hours may give falsely high readings for MCV (mean corpuscular volume),[191] because red blood cells swell as they absorb water from the plasma; and platelet and white blood cell differential results may be inaccurate in aged specimens, as the cells degrade over time.[91]
Samples drawn from individuals with very high levels of bilirubin or lipids in their plasma (referred to as an icteric sample or a lipemic sample, respectively)[192] may show falsely high readings for hemoglobin, because these substances change the colour and opacity of the sample, which interferes with hemoglobin measurement.[193] This effect can be mitigated by replacing the plasma with saline.[91]
Some individuals produce an antibody that causes their platelets to form clumps when their blood is drawn into tubes containing EDTA, the anticoagulant typically used to collect CBC samples. Platelet clumps may be counted as single platelets by automated analyzers, leading to a falsely decreased platelet count. This can be avoided by using an alternative anticoagulant such as sodium citrate or heparin.[194][195]
Another antibody-mediated condition that can affect complete blood count results is
While blast and lymphoma cells can be identified in the manual differential, microscopic examination cannot reliably determine the cells'
History
Before
The physiologist
In the 1870s, Paul Ehrlich developed a staining technique using a combination of an acidic and basic dye that could distinguish different types of white blood cells and allow red blood cell morphology to be examined.[203] Dmitri Leonidovich Romanowsky improved on this technique in the 1890s, using a mixture of eosin and aged methylene blue to produce a wide range of hues not present when either of the stains was used alone. This became the basis for Romanowsky staining, the technique still used to stain blood smears for manual review.[209]
The first techniques for measuring hemoglobin were devised in the late 19th century, and involved visual comparisons of the colour of diluted blood against a known standard.[205] Attempts to automate this process using spectrophotometry and colorimetry were limited by the fact that hemoglobin is present in the blood in many different forms, meaning that it could not be measured at a single wavelength. In 1920, a method to convert the different forms of hemoglobin to one stable form (cyanmethemoglobin or hemiglobincyanide) was introduced, allowing hemoglobin levels to be measured automatically. The cyanmethemoglobin method remains the reference method for hemoglobin measurement and is still used in many automated hematology analyzers.[57][210][211]
Research into automated cell counting began in the early 20th century.
That October, Wallace built a counter to demonstrate the principle. Owing to financial constraints, the aperture was made by burning a hole through a piece of cellophane from a cigarette package.
The first analyzer able to produce multiple cell counts simultaneously was the
After basic cell counting had been automated, the white blood cell differential remained a challenge. Throughout the 1970s, researchers explored two methods for automating the differential count: digital image processing and flow cytometry. Using technology developed in the 1950s and 60s to automate the reading of
Early flow cytometry devices shot beams of light at cells in specific wavelengths and measured the resulting absorbance, fluorescence or light scatter, collecting information about the cells' features and allowing cellular contents such as
Explanatory notes
- ^ Though commonly referred to as such, platelets are technically not cells: they are cell fragments, formed from the cytoplasm of megakaryocytes in the bone marrow.[6]
- ^ The data used to construct reference ranges is usually derived from "normal" subjects, but it is possible for these individuals to have asymptomatic disease.[34]
- ^ In its broadest sense, the term flow cytometry refers to any measurement of the properties of individual cells in a fluid stream,[49][50] and in this respect, all hematology analyzers (except those using digital image processing) are flow cytometers. However, the term is commonly used in reference to light scattering and fluorescence methods, especially those involving the identification of cells using labelled antibodies that bind to cell surface markers (immunophenotyping).[49][51]
- ^ This is not always the case. In some types of thalassemia, for example, a high red blood cell count occurs alongside a low or normal hemoglobin, as the red blood cells are very small.[123][124] The Mentzer index, which compares the MCV to the RBC count, can be used to distinguish between iron deficiency anemia and thalassemia.[125]
- ^ Automated instruments group these three types of cells together under the "immature granulocyte" classification,[142] but they are counted separately in the manual differential.[143]
- ^ The RDW is highly elevated at birth and gradually decreases until approximately six months of age.[178]
- US Navy ships; other accounts claim it was originally designed during the Second World War to count plankton. However, Wallace never worked for the Navy, and his earliest writings on the device state that it was first used to analyze blood. The paint story was eventually retracted from documents produced by the Wallace H. Coulter Foundation.[213]
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