Back to the basics: quantity vs quality.

For RBCs, just like WBCs, we need to assess the basics: o quantity of RBCs. o quality of the RBCs o RBC turnover rate Quantity o Sufficient RBCs, and what's the total hemoglobin? (Hgb, HCT) Quality of the RBCs o Are they beat up? (RDW) o Are they small or large? (MCV) o Their hemoglobin content? (MCH, MCHC) o Do they contain funky stuff? (abnormal hemoglobin, malaria, etc.) Turnover rate and bone marrow capacity to make RBCs (retic count).

Hemoglobin, Hematocrit and Red Cell Count

Total hemoglobin varies with age. o Adult male reference range = 14-18 gm/dL o Adult female reference range = 12-16 gm/dL Hematocrit is a determination of red cell mass, expressed as percent of RBCs per volume of whole blood. o Adult male values = 42-52% o Adult female = 37-47% Red cell count is the total number of RBCs per cc of blood.

Red Cell Distribution Width (RDW)

RDW is an expression of the homogeneity of the RBC population size. (Roll the cursor over the image.)

A large RDW says there's a wide variation in the RBC diameters within the test pool. It doesn't say the cells are large or small, rather that the population is not homogenous. Younger cells are larger (reticulocytes). Older, and generally beat up, RBCs are smaller

Mean Cell Volume (MCV)

This is the average size of the RBCs. Size varies with nutritional status: o Iron deficiency results in smaller cells. o Folic acid and B12 deficiency results in larger cells. Size varies with age and general health of the RBC o Younger cells are larger. o Older and fragmented cells are smaller. Typical adult value is 76-96 fL Although the instrument measures this directly, here's how you can calculate the value yourself. MCV = Hematocrit (%) X 10 RBC count (millions/cubic mm)

MCH and MCHC

Expressions of how much hemoglobin is in each RBC. MCHC = mean cell hemoglobin concentration MCHC = MCH = mean cell hemoglobin MCH = Hemoglobin (gm/ liter) X 10 RBC count (millions/cu mm) Hemoglobin (g/dL) X 100 Hematocrit (%)

Truthfully, these calculated values aren't all that helpful. o They tend to parallel the MCV o Abnormalities reflect RBC cellular problems.

Microcytic anemias

General features of microcytic anemias Small, hypochromic (poorly colored) RBCs Wide RDW, small MCV, low MCH and MCHC. Iron deficiency (poor diet or bad absorption). Chronic blood loss. Inherited defects of RBC structure (hereditary spherocytosis).

Macrocytic anemias

General features of macrocytic anemias.

Large pale cells Large MCV and RDW (cursor). Low MCH and MCHC. Folic acid and B12 deficiencies. Hypersegmented PMNs

Platelets are handled in manner similar to RBCs.

Like everything else in the CBC, it's quality and quantity.

Numbers of platelets o Too many How high? Could it be a reaction to recent hemorrhage? Patient's age? Kids tend to have higher values. Run away production; malignant or benign (?) o Too few The bone marrow can't make them. They're being destroyed or used up peripherally. Are the platelets functioning? o Snockered with some medication, like aspirin. o Snockered because of a disease like renal failure or multiple myeloma.

It's not as easy as "Just give me the numbers. I'm the Doc, I'll figure it out." The values have to fit the clinical situation.

A very straightforward example.

Simple, no platelets. Now to help your patient, all you have to do is figure why.

Sources of error
The biggest source of error is not matching the results with clinical situation. Not just for the CBC, this one'll get you for everything. Clerical errors. o Right name (?), bar code (?) o Did the results go in the wrong chart? o Can you really read that FAXed copy? Sampling errors. o With a clotted sample, nothing is valid. (If you draw the blood in a syringe and then try injecting it into the anti-coagulated tube, it'll clot every time, even if it doesn't look it.) o Did you draw the sample above an IV line? Is it diluted with fluid?

If the tubes aren't kept rocking right up until the moment the aliquot is sent into the machine, the cells will settle out and the aliquot won't be representative. (You know, did the aliquot come from the cell rich end of the tube?) Errors of judgment. o Is the problem with the quality of the cellular elements? o Is the problem with the quantity of the cellular elements?