oh, ship! - dialog.roche.com · • marked anisopoikilocytosis • prominent polychromasia •...

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