oh, ship! - dialog.roche.com · • marked anisopoikilocytosis • prominent polychromasia •...
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Oh, Ship!Jessica Bungard
SCL Dunedin
• 2 x XN20 Units
• SP-10
• Track System
• Cobas IT3000 HPS
“Insufficient Blood Volume (short sample)”
• Check sample volume
• Check sample for clots
• Remix and rerun the sample
• No stop/rerun plus a
functional error present
(from XN)
• Then a stop/rerun is
requested
• If there is no ACTION
already present
• CBC retest
• ACTION analyte is set to
“Rerun_func”
“Insufficient Blood Volume (short sample)”
• Check sample volume
• Check sample for clots
• Remix and rerun the sample
• Could it be a low haemoglobin? Deactivate the aspiration sensor and
reanalyse the sample
• No stop/rerun and a
functional error present
(from XN)
• Then a stop/rerun is
requested
• ACTION already present
• Rerun ACTION analyte and
set to “Check sample”
• Haemoglobin < 75, no reticulocyte count, no stop/rerun
• Then request CBC retest
• No reticulocyte reflex
• Add Reticulocyte
• No film analyte already requested
• Then request film
Full Blood Count Ref. Range
RBC x10 ^12 /L 0.56 * (4.30 - 6.00)
Haemoglobin g/L 31 * (130 - 175)
Hct 0.09 * (0.40 - 0.52)
MCV fl 152 * (80 - 99)
MCH pg 55 * (27 - 33)
MCHC g/L 365 (300 - 365)
MPV fL 10.3 (7.2 - 12.0)
Platelets x10 ^9 /L 290 (150 - 400)
WBC x10 ^9 /L 6.2 (4.0 - 11.0)
Neutrophils x10 ^9 /L 5.3 (1.9 - 7.5)
Lymphocytes x10 ^9 /L 0.5 * (1.0 - 4.0)
Monocytes x10 ^9 /L 0.4 (0.2 - 1.0)
Eosinophils x10 ^9 /L 0.0 (< 0.6)
Basophils x10 ^9 /L 0.0 (< 0.3)
NRBC /100 WBC 6
RDW-CV % 25.7 * (11.5 - 15.0)
Retic. Count x10 ^9 /L 170 * (20 - 100)
Aspiration Sensor
• 88µL
• Blank + Sample
Conversion values
Algorithm
• Adequate sample for
analysis
Aspiration Sensor
• “Blood cannot be aspirated” or “Insufficient blood volume (short sample)”
• Caused by
• Short samples, clotted samples inadequate sample aspirated
• Low haemoglobin samples colourless/less turbid is this even blood?!?
“Difference between RBC and RET. Check the results.”
• Generated based on the ratio of the RBC result from the RET channel (RBC-O) and RBC result from the
impedance channel
• Calculated as (RBC-O/RBC)
• Generated when >1.2 or <0.8
• Possible actions:
• Film examination for abnormal morphology (agglutination, polychromasia, NRBCs, Howell-Jolly
Bodies, parasites)
• Verifying the reticulocyte count using an alternate method
Full Blood Count Ref. Range
RBC x10 ^12 /L 0.56 * (4.30 - 6.00)
Haemoglobin g/L 31 * (130 - 175)
Hct 0.09 * (0.40 - 0.52)
MCV fl 152 * (80 - 99)
MCH pg 55 * (27 - 33)
MCHC g/L 365 (300 - 365)
MPV fL 10.3 (7.2 - 12.0)
Platelets x10 ^9 /L 290 (150 - 400)
WBC x10 ^9 /L 6.2 (4.0 - 11.0)
Neutrophils x10 ^9 /L 5.3 (1.9 - 7.5)
Lymphocytes x10 ^9 /L 0.5 * (1.0 - 4.0)
Monocytes x10 ^9 /L 0.4 (0.2 - 1.0)
Eosinophils x10 ^9 /L 0.0 (< 0.6)
Basophils x10 ^9 /L 0.0 (< 0.3)
NRBC /100 WBC 6
RDW-CV % 25.7 * (11.5 - 15.0)
Retic. Count x10 ^9 /L 170 * (20 - 100)
Case
• 40 year old male
• Urgent doctors – international patient
• Address was India
• No previous results in our system
• “Previously anaemic, Hb 98 with macrocytes in May 2018” (now July, Hb 31)
• “Clinically has ongoing symptoms of anaemia”
• Need a repeat from the patient to check results
• On a ship at Port Otago
Full Blood Count Ref. Range
RBC x10 ^12 /L 0.56 0.46 * (4.30 - 6.00)
Haemoglobin g/L 31 26 * (130 - 175)
Hct 0.09 0.07 * (0.40 - 0.52)
MCV fl 152 150 * (80 - 99)
MCH pg 55 57 * (27 - 33)
MCHC g/L 365 377 * (300 - 365)
MPV fL 10.3 10.0 (7.2 - 12.0)
Platelets x10 ^9 /L 290 269 (150 - 400)
WBC x10 ^9 /L 6.2 5.6 (4.0 - 11.0)
Neutrophils x10 ^9 /L 5.3 4.8 (1.9 - 7.5)
Lymphocytes x10 ^9 /L 0.5 0.5 (1.0 - 4.0)
Monocytes x10 ^9 /L 0.4 0.3 (0.2 - 1.0)
Eosinophils x10 ^9 /L 0.0 0.0 (< 0.6)
Basophils x10 ^9 /L 0.0 0.0 (< 0.3)
NRBC /100 WBC 6 7
RDW-CV % 25.7 (11.5 - 15.0)
Retic. Count x10 ^9 /L 170 154 * (20 - 100)
Vitamin B12 & Folate
Ref. Range
Serum B12 330 pmol/L (170 - 600)
Serum Folate 8.5 nmol/L (> 6.0)
Iron Studies
Ref. Range
Serum Iron umol/L 56 * (10 - 30)
Transferrin g/L 2.5 (2.0 - 3.5)
Transf sat % 89 * (16 - 50)
Ferritin ug/L 959 * (20 - 500)
• On iron or multivitamins?
• Prescribed iron for his previous anaemia?
C-Reactive Protein Ref. Range
CRP 9 * (< 5)
Renal Function Tests
Ref. Range
Sodium mmol/L 131 * (135 - 145)
Potassium mmol/L 4.3 (3.5 - 5.2)
Urea mmol/L 6.2 (3.2 - 7.7)
Creatinine umol/L 80 (50 - 110)
eGFR > 90
(mL/min/1.73m2)
Liver Functions
Ref. Range
Total Bilirubin umol/L 75 * (2 - 20)
Conj. Bilirubin umol/L 12 * (< 6)
Alk.Phosphatase U/L 80 (30 - 150)
GGT U/L 20 (10 - 50)
ALT U/L 14 (0 - 40)
AST U/L 32 (10 - 50)
Total Protein g/L 68 (64 - 83)
Albumin g/L 37 (32 - 48)
Globulin g/L 31 (25 - 41)
Muscle Enzymes
Ref. Range
LD U/L 680 * (110 - 220)
Haptoglobin
Ref.Range
Haptoglobin g/L < 0.05 * (0.30 - 2.70)
Direct Antiglobulin Test (Coombs Test)
Direct Coombs Indeterminate
Interpretation is indeterminate as auto-control is positive even when warmed to 37°C.
• Anaemic, high reticulocyte count
• Elevated bilirubin, conjugated bilirubin raised
• High lactate dehydrogenase and low haptoglobin
• Indeterminate DAT
• Haemolytic anaemia
• ? Antibody of some sort
Coagulation Tests Ref. Range
P.T. Secs 12.8 (9.0 - 13.0)
INR 1.2 (0.8 - 1.2)
A.P.T.T. Secs 22 (20 - 31)
Fibrinogen Level g/L 4.1 (1.7 - 4.3)
Haematologist comment:
• Severe anaemia
• Leukoerythroblastic blood picture
• Marked anisopoikilocytosis
• Prominent polychromasia
• Teardrop cells, irregular contracted cells, Howell-Jolly bodies and nucleated red cells.
• Small numbers of spherocytes
• Granulocytes are increased and left shifted
• Is there any past history of haematological disorder?
• Overerall the blood film findings are consistent with bone marrow stress and the differential for that
include acute red cell haemolysis or blood loss, myelofibrosis or marrow infiltration.
Case
Case
• Non English speaker, interpreter used
• Tired, dizzy past 20 days
• No chest pain, shortness of breath, loss of consciousness, fever or chills
• No bleeding
• No bone pain, weight loss or night sweats
• No known previous blood disorders or childhood illnesses
• Haemoglobin of 98 before leaving India. Treated with iron, folic acid and B12 supplement
Case
• RBC units needed
• B positive, Autoantibody present
• Advised that “provision of blood for transfusion might be delayed” due to the
presence of the autoantibody
• Antibody identification – not successful. Sample to be sent to Auckland
• Antibody never identified
• International patient = Unfunded
• Company manager paying for hospital stay and tests, until able to fly home for definitive treatment
• Limited testing
CasePrimary diagnosis: Autoimmune Haemolytic Anaemia
• Significant levels of autoantibodies present
• Current compensation but risk of deterioration
• 1 x unit overnight
• 3 x units next day
• Prednisone for immune suppression
• Omeprazole for gastric protection from steroid
Full Blood Count 18/07/18 18/07/18 18/07/18 19/07/18 19/07/18 20/07/18
11:35 14:36 17:16 11:35 15:43 07:50 Ref. Range
RBC x10 ^12 /L 0.56 0.46 0.60 1.07 1.40 2.17 (4.30 - 6.00)
Haemoglobin g/L 31 26 28 40 50 74 (130 - 175)
Hct 0.09 0.07 0.09 0.13 0.16 0.24 (0.40 - 0.52)
MCV fl 152 150 145 122 116 111 (80 - 99)
MCH pg 55 57 47 37 36 34 (27 - 33)
MCHC g/L 365 377 322 305 307 308 (300 - 365)
MPV fL 10.3 10.0 9.9 10.0 10.2 10.2 (7.2 - 12.0)
Platelets x10 ^9 /L 290 269 316 302 288 265 (150 - 400)
WBC x10 ^9 /L 6.2 5.6 6.6 5.6 5.5 6.0 (4.0 - 11.0)
Neutrophils x10 ^9 /L 5.3 4.8 5.5 4.7 4.8 4.9 (1.9 - 7.5)
Lymphocytes x10 ^9 /L 0.5 0.5 0.8 0.6 0.4 0.7 (1.0 - 4.0)
Monocytes x10 ^9 /L 0.4 0.3 0.3 0.4 0.3 0.4 (0.2 - 1.0)
Eosinophils x10 ^9 /L 0.0 0.0 0.0 0.0 0.0 0.0 (< 0.6)
Basophils x10 ^9 /L 0.0 0.0 0.0 0.0 0.0 0.0 (< 0.3)
NRBC /100 WBC 6 7 7 6 8 6
RDW-CV % 25.7 28.1 30.0 (11.5 - 15.0)
Retic. Count x10 ^9 /L 170 154 206 314 319 (20 - 100)
Thank you.Jessica Bungard, SCL Dunedin