Complete blood count
A complete blood count, also known as a full blood count or full haemogram, is a set of medical laboratory tests that provide information about the cells in a person's blood. The CBC indicates the counts of white blood cells, red blood cells and platelets, the concentration of hemoglobin, and the hematocrit. The red blood cell indices, which indicate the average size and hemoglobin content of red blood cells, are also reported, and a white blood cell differential, which counts the different types of white blood cells, may be included.
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 reference ranges, which vary with sex and age. Conditions like anemia and thrombocytopenia are defined by abnormal complete blood count results. The red blood cell indices can provide information about the cause of a person's anemia such as iron deficiency and vitamin B12 deficiency, and the results of the white blood cell differential can help to diagnose viral, bacterial and parasitic infections and blood disorders like leukaemia. Not all results falling outside of the reference range require medical intervention.
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, 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, Karl Vierordt published the first procedure for performing a blood count, which involved spreading a known volume of blood on a microscope slide and counting every cell. The invention of the hemocytometer in 1874 by Louis-Charles Malassez simplified the microscopic analysis of blood cells, and in the late 19th century, Paul Ehrlich and Dmitri Leonidovich Romanowsky developed techniques for staining white and red blood cells that are still used to examine blood smears. Automated methods for measuring hemoglobin were developed in the 1920s, and Maxwell Wintrobe introduced the Wintrobe hematocrit method in 1929, which in turn allowed him to define the red blood cell indices. A landmark in the automation of blood cell counts was the Coulter principle, which was patented by Wallace H. Coulter in 1953. The Coulter principle uses electrical impedance measurements to count blood cells and determine their sizes; it is a technology that remains in use in many automated analyzers. Further research in the 1970s involved the use of optical measurements to count and identify cells, which enabled the automation of the white blood cell differential.
Purpose
Blood is composed of a fluid portion, called plasma, and a cellular portion that contains red blood cells, white blood cells and platelets. The complete blood count evaluates the three cellular components of blood. Some medical conditions, such as anemia or thrombocytopenia, are defined by marked increases or decreases in blood cell counts. Changes in many organ systems may affect the blood, so CBC results are useful for investigating a wide range of conditions. Because of the amount of information it provides, the complete blood count is one of the most commonly performed medical laboratory tests.The CBC is often used to screen for diseases as part of a medical assessment. It is also called for when a healthcare provider suspects a person has a disease that affects blood cells, such as an infection, a bleeding disorder, or some cancers. People who have been diagnosed with disorders that may cause abnormal CBC results or who are receiving treatments that can affect blood cell counts may have a regular CBC performed to monitor their health, and the test is often performed each day on people who are hospitalized. The results may indicate a need for a blood or platelet transfusion.
The complete blood count has specific applications in many medical specialties. It is often performed before a person undergoes surgery to detect anemia, ensure that platelet levels are sufficient, and screen for infection, as well as after surgery, so that blood loss can be monitored. In emergency medicine, the CBC is used to investigate numerous symptoms, such as fever, abdominal pain, and shortness of breath, and to assess bleeding and trauma. Blood counts are closely monitored in people undergoing chemotherapy or radiation therapy for cancer, because these treatments suppress the production of blood cells in the bone marrow and can produce severely low levels of white blood cells, platelets and hemoglobin. Regular CBCs are necessary for people taking some psychiatric drugs, such as clozapine and carbamazepine, which in rare cases can cause a life-threatening drop in the number of white blood cells. Because anemia during pregnancy can result in poorer outcomes for the mother and her baby, the complete blood count is a routine part of prenatal care; and in newborn babies, a CBC may be needed to investigate jaundice or to count the number of immature cells in the white blood cell differential, which can be an indicator of sepsis.
The complete blood count is an essential tool of hematology, which is the study of the cause, prognosis, treatment, and prevention of diseases related to blood. The results of the CBC and smear examination reflect the functioning of the hematopoietic system—the organs and tissues involved in the production and development of blood cells, particularly the bone marrow. For example, a low count of all three cell types can indicate that blood cell production is being affected by a marrow disorder, and a bone marrow examination can further investigate the cause. Abnormal cells on the blood smear might indicate acute leukaemia or lymphoma, while an abnormally high count of neutrophils or lymphocytes, in combination with indicative symptoms and blood smear findings, may raise suspicion of a myeloproliferative disorder or lymphoproliferative disorder. Examination of the CBC results and blood smear can help to distinguish between causes of anemia, such as nutritional deficiencies, bone marrow disorders, acquired hemolytic anemias and inherited conditions like sickle cell anemia and thalassemia.
The reference ranges for the complete blood count represent the range of results found in 95% of apparently healthy people. By definition, 5% of results will always fall outside this range, so some abnormal results may reflect natural variation rather than signifying a medical issue. This is particularly likely if such results are only slightly outside the reference range, if they are consistent with previous results, or if there are no other related abnormalities shown by the CBC. When the test is performed on a relatively healthy population, the number of clinically insignificant abnormalities may exceed the number of results that represent disease. For this reason, professional organizations in the United States, United Kingdom and Canada recommend against pre-operative CBC testing for low-risk surgeries in individuals without relevant medical conditions. Repeated blood draws for hematology testing in hospitalized patients can contribute to hospital-acquired anemia and may result in unnecessary transfusions.
Procedure
The sample is collected by drawing blood into a tube containing an anticoagulant—typically EDTA—to stop its natural clotting. The blood is usually taken from a vein, but when this is difficult it may be collected from capillaries by a fingerstick, or by a heelprick in babies. Testing is typically performed on an automated analyzer, but manual techniques such as a blood smear examination or manual hematocrit test can be used to investigate abnormal results. Cell counts and hemoglobin measurements are performed manually in laboratories lacking access to automated instruments.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. 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. 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.File:Sysmex XT-4000i.jpg|thumb|Sysmex XT-4000i automated hematology analyzer|alt=CBC samples in a rack, waiting to be run on a bench-top analyzer
To measure the hemoglobin concentration, a reagent chemical is added to the sample to destroy the red cells in a channel separate from that used for red blood cell counts. On analyzers that perform white blood cell counts in the same channel as hemoglobin measurement, this permits white blood cells to be counted more easily. Hematology analyzers measure hemoglobin using spectrophotometry and are based on the linear relationship between the absorbance of light and the amount of hemoglobin present. Chemicals are used to convert different forms of hemoglobin, such as oxyhemoglobin and carboxyhemoglobin, to one stable form, usually cyanmethemoglobin, and to create a permanent colour change. The absorbance of the resulting colour, when measured at a specific wavelength—usually 540 nanometres—corresponds with the concentration of hemoglobin.
Sensors count and identify the cells in the sample using two main principles: electrical impedance and light scattering. Impedance-based cell counting operates on the Coulter principle: cells are suspended in a fluid carrying an electric current, and as they pass through a small opening, they cause decreases in current because of their poor electrical conductivity. The amplitude of the voltage pulse generated as a cell crosses the aperture correlates with the amount of fluid displaced by the cell, and thus the cell's volume, while the total number of pulses correlates with the number of cells in the sample. The distribution of cell volumes is plotted on a histogram, and by setting volume thresholds based on the typical sizes of each type of cell, the different cell populations can be identified and counted.
In light scattering techniques, light from a laser or a tungsten-halogen lamp is directed at the stream of cells to collect information about their size and structure. Cells scatter light at different angles as they pass through the beam, which is detected using photometers. Forward scatter, which refers to the amount of light scattered along the beam's axis, is mainly caused by diffraction of light and correlates with cellular size, while side scatter is caused by reflection and refraction and provides information about cellular complexity.
Radiofrequency-based methods can be used in combination with impedance. These techniques work on the same principle of measuring the interruption in current as cells pass through an aperture, but since the high-frequency RF current penetrates into the cells, the amplitude of the resulting pulse relates to factors like the relative size of the nucleus, the nucleus's structure, and the amount of granules in the cytoplasm. Small red cells and cellular debris, which are similar in size to platelets, may interfere with the platelet count, and large platelets may not be counted accurately, so some analyzers use additional techniques to measure platelets, such as fluorescent staining, multi-angle light scatter and monoclonal antibody tagging.
Most analyzers directly measure the average size of red blood cells, which is called the mean cell volume, and calculate the hematocrit by multiplying the red blood cell count by the MCV. Some measure the hematocrit by comparing the total volume of red blood cells to the volume of blood sampled, and derive the MCV from the hematocrit and red blood cell count. The hemoglobin concentration, the red blood cell count and the hematocrit are used to calculate the average amount of hemoglobin within each red blood cell, the mean corpuscular hemoglobin ; and its concentration, the mean corpuscular hemoglobin concentration. Another calculation, the red blood cell distribution width, is derived from the standard deviation of the mean cell volume and reflects variation in cellular size.
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 granulocytes, lymphocytes, and other mononuclear cells, allowing a three-part differential to be performed based on cell volume alone. More advanced analyzers use additional techniques to provide a five- to seven-part differential, such as light scattering or radiofrequency analysis, or using dyes to stain specific chemicals inside cells—for example, nucleic acids, which are found in higher concentrations in immature cells or myeloperoxidase, an enzyme found in cells of the myeloid lineage. Basophils may be counted in a separate channel where a reagent destroys other white cells and leaves basophils intact. The data collected from these measurements is analyzed and plotted on a scattergram, where it forms clusters that correlate with each white blood cell type. Another approach to automating the differential count is the use of digital microscopy software, which uses artificial intelligence to classify white blood cells from photomicrographs of the blood smear. The cell images are displayed to a human operator, who can manually re-classify the cells if necessary.
Most analyzers take less than a minute to run all the tests in the complete blood count. Because analyzers sample and count many individual cells, the results are very precise. 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.