correction – Flashcards

High numbers of WBCs can cause a false decrease in the WBC reported. To correct a high WBC count: 1. WAM holds results. 2. Perform a 1:5 dilution of the specimen (Add 100 mcL of specimen to 400 mcL of CellPack diluent.) 3. Run on capillary mode of instrument within 20 minutes of setup. (See CBCD and Reticulocyte procedure). As a QC check, verify that the RBC count agrees within + 0.1 of undiluted sample. If not, rerun sample. If still not acceptable, remake dilution. Notify supervisor if unable to resolve. 4. When run in the capillary mode, the instrument automatically multiplies the results by 5 and sends them to WAM. 5. Accept the WBC count if the RBC count agrees + 0.1 of original RBC count. 6. In WAM, add internal comment "By dilution". NOTE: The HGB and WBC are measured in different chambers on Sysmex analyzers, so there is no WBC interference with the HGB result

Cold agglutinins cause the spontaneous agglutination of RBCs at temperatures lower than 37oC. The degree of agglutination is dependent on the cold agglutinin titer. Due to the fact that the Sample Rotor Valve (SRV) on the Sysmex analyzers is warmed to 37oC, only strong cold agglutinins will be apparent. The strong cold agglutinins will cause spurious low RBC counts due to counting micro-agglutinates as single cells. Also, the MCV will be falsely elevated due to micro-agglutinates being sized as a single large cell. The hemoglobin reading is usually correct. Also, with a correct hemoglobin value and low hematocrit, the MCHC (Hgb/HCT x 100 = MCHC) and the MCH (MCV x MCHC/100 = MCH) will be spuriously elevated. Check for cold agglutination on all bloods with: (a) "MCHC" greater than 38%; (b) smear and hematology analyzer MCV do not agree (NOTE: MCV does not necessarily have to be macrocytic to be suspicious of a cold agglutinin); (c) smears with RBC agglutinates; or (d) any blood you are suspicious of because of a "lacy" appearance in the tube or on the slide. If b, c, or d is present, follow cold agglutinin procedure, regardless of MCHC value. To correct for the effect of a cold agglutinin: 1. Place the blood in a 37oC incubator (e.g., heating block or coagulation water bath) for at least 15 minutes. 2. Mix specimen thoroughly and rerun the blood through the open mode of the hematology analyzer. (So specimen doesn't cool down). 3. Report the 37oC results (for all parameters) if the MCHC is feasible. (See Figures 1 and 2 below.) 4. In WAM, add "Possible Cold Agglutinin" comment by double clicking on COM field next to MCHC result and selecting HE03, then SAVE. 5. For a cold agglutinin specimen that has instrument flags/lab values requiring microscopic review: If RBC agglutinates are present, make warmed smears to see if the agglutinates go away upon warming. Regardless of which smears (room temp or warmed) exhibit agglutinates, report "RBC agglutinates present". If case needs further review by a pathologist, submit both sets of clearly marked slides to the pathologist. NOTE: Cold agglutinins must always be incubated at 37oC before being reporting as such.

can cause a falsely elevated hemoglobin due to a cloudy SLS-hemoglobin solution which decreases the amount of transmitted light through the solution to the photocell. (Lipemia usually occurs in patients with hyperchylomicronemia whose triglycerides are greater than 1,000 mg/dL.) Lipemia should be suspected on all bloods with: (a) a lacy appearance of blood smear or (b) an MCHC over 36.5. Action must be taken on MCHCs greater than 38%. To check for lipemia, spin blood for approximately 5 minutes (or let settle for approximately 10-15 minutes) and visually check plasma layer for characteristic milky appearance. To correct for lipemia perform either of the following procedures: Plasma Replacement: 1. Spin down a PORTION of the blood specimen at 2000 rpm for 5 minutes. 2. Mark the top (meniscus) of the plasma level. 3. Carefully remove most, but not all, of the plasma. 4. Replace the plasma with the same amount of Cell Pack diluent (add diluent up to the mark). 5. Mix the sample and cycle through the instrument. 6. Use the RBC result as a guide to verify proper re-dilution of the specimen. 7. If the RBC result is within + 0.10 of the original RBC, report the Hgb, from the re- diluted sample. 8. Recalculate the MCH and MCHC using the new HGB and original RBC and HCT.

1. Spin a portion of the blood. 2. Perform a hemoglobin on the PLASMA using the hematology analyzer open mode. 3. Use the following formula to calculate the correct hemoglobin: Corrected HGB = Original HGB - [(1-{Original HCT/100}) x Plasma HGB] Example: WBC 5.1 RBC 4.03 HGB 16.1 HCT 39.3 MCV 97.5 MCH 40.0 MCHC 41.3 PLT 250 Plasma Hgb 4.5 Corrected HGB = 16.1 - [(1-[39.3/100]) x 4.5] = 16.1 - [(1-.0393} x 4.5] = 16.1 - [0.607 x 4.5] = 16.1 - 2.7315 = 13.4 4. Recalculate the MCH and MCHC using new HGB and original RBC and HCT. Corrected report: WBC 5.1 RBC 4.03 HGB 13.4 HCT 39.3 MCV 97.5 MCH 33.3 MCHC 34.1 PLT 250 5. In WAM, add "Corrected for Lipemia" comment by double clicking on COM field next to MCHC result field and selecting HE02, then SAVE. (See Note 1.) NOTE: To avoid any math errors, have second technologist verify calculations.

If interference from bilirubin is suspected, a correct hemoglobin value may be obtained by performing one of the correction procedures described on the previous page for LIPEMIA and free-texting "Corrected for ICTERIA" as an internal comment.

Cold-precipitated plasma immunoglobulins (cryoglobulin) or fibrinogen (cryofibrinogen) in a blood sample can cause a falsely increased WBC count with excessively high takeoff at 35 fL resulting in a voteout (-----) and/or * code for the WBC parameter. Also, the RBC count, hemoglobin, hematocrit and platelet count may be slightly increased along with a slightly decreased MCV. (See results in Figures 1 and 2 below.) Aggregates of blue staining amorphous material may be seen on Wright stained smears. Increased levels of cryoglobulin may be associated with myeloma, macroglobulinemia, lymphoproliferative disorders (e.g. CLL), metatastic tumors, autoimmune disorders, infection, and as an idiopathic disease. Cryofibrinogen has been observed in association with many disorders including myeloma, carcinoma, leukemia, aneurysm, pregnancy, the use of oral contraceptives, thromboembolic phenomena, diabetes, and as an essential disease. To correct for the effects of a cryoglobulin: 1. Warm specimen to 37oC for a minimum of 15 minutes. 2. Rerun through the hematology analyzer open mode. 3. Report the 37oC results (for all parameters) if the results are feasible and no parameter flags are present. 4. In WAM, free-text internal comment "Possible cryoglobulin".

If an "NRBC?" flag is triggered, the specimen will reflex for a numerical value and corrected WBC count and corrected lymphocyte. The comment "WBC corrected for NRBCs" will automatically be added to the WBC field by WAM. WBH XE-Series (2100 and 5000) NRBC counts are linear to 464 per 100 WBC. 1. If performing a scan and greater than 5 NRBCs are seen that were not reported by the hematology analyzer, report corrected WBC as follows: a. If sufficient specimen remains, order CBCWD and Retic in WAM or on hematology analyzer then run specimen to obtain corrected WBC and NRBC value. Correct report in Soft LAB. Add comment "WBC corrected for NRBC" to WBC field. Call corrected WBC to physician or nursing unit as applicable. b. If insufficient specimen remains, perform differential using Downtime Cell Counter software loaded onto PCs at morphology bench. The software program will automatically correct WBC count and correct the differential absolutes. (Make sure you enter the WBC count in the cell counter so that the NRBCs will calculate). Correct report in SoftLAB.) Add comment "Corrected for NRBCS" to the WBC field. (See example below.) 2. Calculations: a. Original absolute # x Corrected WBC = New absolute # Original WBC b. Original absolute # x 100 = New absolute # 100 + NRBC

Platelet clumping can result in spurious low and widely fluctuating platelet counts on hematology instruments. Platelet clumping may occur because of poor collection technique resulting in the presence of micro clots, delays in mixing the blood and anticoagulant, the presence of platelet agglutinins, or EDTA-induced clumping. Check for platelet clumping by first checking for a clot. Document as internal comment in WAM. Then examine a peripheral smear on all bloods with the following instrument flags or results: a) platelet count less than 75 bill/L b) platelet clump(s) flag c) platelet clumps flag d) platelet delta check (decrease only) The WAM holds results. To correct for platelet clumping: 1. Examine Wright stained smear for clumping - particularly at the feathered and side (lateral) edges. 2. If platelet clumps are seen: a) Scan peripheral smear to determine if WBC estimate matches instrument count. b) If estimate does not match instrument count, add comment "WBC may be inaccurate due to WBC/PLT interference" to WBC comment field. c) Note approximate platelet estimate from stained smear (e.g., ADQ, INC, DEC); and d) In WAM Result Validation tab, remove platelet result by clicking on Platelet Result field, then clicking Delete. Double click on the Platelet Result field. A window opens. Select the appropriate clumped platelet comment that correlates with the platelet estimate: "Platelets clumped in EDTA, appear adequate on smear." "Platelets clumped in EDTA, appear decreased on smear." "Platelets clumped in EDTA, appear increased on smear." (See example below.)

is the adherence of platelets to neutrophils and is seen only in EDTA- anticoagulated blood. Platelet satellitosis can cause spurious low or fluctuating platelet counts on hematology instruments. In addition, spurious neutropenia can occur in white cell differentials performed on wedge blood smears. Check for platelet satellitosis by examining feathered edges of a blood smear on all bloods with: a) platelet counts less than 75 bill/L or b) widely different platelet results from previously reported values To correct for platelet satellitosis: 1. Note approximate platelet estimate (ADQ, INC, DEC) from stained smear. 2. Delete PLT result from WAM and replace with the statement: "Platelet satellitosis in EDTA - Appear (platelet estimate)". 3. Report hematology analyzer differential if scan agrees; otherwise perform manual diff. 4. A numerical platelet count may be attempted, if physician requests, by re-collecting in sodium citrate (blue-top tube). Multiply PLT results by 1.1 to correct for dilution effect. If sodium citrate does not correct problem, remove PLT value from WAM and add comment "Unable to report due to xxx". ______________________________________________________

Scan the peripheral smear for the presence of fragmented RBCs and other RBC abnormalities. If extremely microcytic RBC are present: a) Estimate the PLT count b) If the RET was not ordered, there may be an Action Message stating, "Count RET Channel". You may reanalyze the specimen in the CBC + RET mode. The XE judges whether or not to switch to report the PLT-O.

Per Debbie Fitzwater, Sysmex Hematology Applications Specialist, the Sysmex hematology analyzers have floating discriminators so there should be no interferences in CBC results from giant platelets. If there is instrument/ smear disagreement, add the following comment to the WBC field: "WBC may be inaccurate due to WBC/PLT interference."

In vitro hemolysis of red cells after sample collection may lead to a spuriously low RBC count and hematocrit. Extensive in vivo hemolysis may lead to a falsely elevated hemoglobin value that represents both plasma and red cell hemoglobin. Thus the MCH and MCHC may be spuriously elevated. (Measured values for red cell count and hematocrit are still correct.) If in vivo hemolysis is suspected: 1. Perform the plasma replacement procedure described under "LIPEMIA" above and recalculate the MCH and MCHC with the new corrected hemoglobin. 2. Verify platelet count on blood smear. 3. Free-text the internal comment: "Corrected for hemolysis".

Red blood cells containing large amounts of abnormal hemoglobin S or C may be more resistant to lysis. Due to RBC lyse resistance, the WBC count from the DIFF scattergram may be suspect. However, a correct count is derived from the WBC channel, which has a stronger lysing reagent. To correct for the presence of RBC lyse resistance, verify the hematology analyzer WBC against a WBC estimate from the peripheral smear. ______________________________________________________________

The presence of elevated WBC counts, lipemia, icteria, cold agglutinins, cryoglobulins, nucleated RBCs, or platelet clumping/satellitosis, giant platelets, microcytic / fragmented / RBC lyse resistance, and hemolysis is not found in normal blood.

1. In some situations a corrected value may be unable to be obtained. If a corrected value cannot be obtained by manual methods, add the comment "Unable to perform " to the affected parameter in SoftLAB. This adds "See below" to the result field and then the comment below that on the instant report. Consult supervisor if further direction is needed. 2. Instrument voteouts will come across into WAM as "#nm". This translates to "Unable to perform" in the LIS. 3. If physician requests a platelet result on a patient with EDTA-induced platelet clumping, a platelet count may be able to be reported from a venous sample collected in FULL 3.2% citrate tube (corrected x 1.1 for dilution) as long as the citrate smear does not exhibit clumping and the citrate platelet count is higher than the EDTA platelet count.