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UNDERSTANDING THE CBC WITH DIFFERENTIAL

Table 1. Complete Blood Count

WBC Differential white cell count RBC

4,500 to 11,000/ L See Table 7 4.0 to 6.2 million/ L

Hct Women Men 8 to 64 yr Men 65 to 74 yr

35% to 47% 39% to 50% 37% to 51%

Hgb Women Men

12 to 16 g/dL 14 to 18 g/dL

RBC indices Mean corpuscular volume Mean corpuscular Hgb Mean corpuscular Hgb concentration Platelet count

82 to 93 m 3 26 to 34 pg 31% to 38% 150,000 to 400,000 L

Data from Chernecky et al. 1

marrow, which include disorders such as ane- mia, leukemia, polycythemia, thrombocytosis, and thrombocytopenia. The CBC also evaluates medical conditions that secondarily affect the blood and bone marrow resulting in hemato- logic manifestations such as infection, inam- mation, coagulopathies, neoplasms, and toxic substance exposure. In many instances, specic symptomatology of a medical condition may not be present and hematologic changes on the CBC may be the only nding present. These changes prompt investigation to then identify the medical condition.

To foster the understanding of the usefulness of the CBC, the function and life cycle of the various cells are introduced. Test indications, characteristics, abnormal ndings, and applica- tions for the perianesthesia nurse are discussed.

Screening

Screeningusually refers to testing patients who are asymptomatic and have no physical signs of disease. However, symptoms or physi- cal signs may be very insensitive indicators of some diseases. In the perianesthesia setting, the use of the CBC as a screening tool constantly undergoes revision. Factors such as the preva- lence of disease in a population, the medical and nancial impact of missing a problem,the cost per problem found, nancial reimburse-

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ment, and societal judgments determine when screening tests are indicated. Medicare does not support the use of the CBC as a screening tool; to be cost effective, the CBC should only be ordered when indicated. 2

Indications

Preoperative evaluation should include a his- tory, a physical examination, laboratory tests, and an assessment of surgical risk to identify coexisting diseases and complicating condi- tions. To decrease the risk of morbidity and mortality in the perianesthesia setting, the CBC is used to assist with the identication of pa- tients who are at risk for complications of inad- equate tissue perfusion during the procedure and those with a possible infectious or inam- matory process. 3,4

General indications for a CBC that are consid- ered medically reasonable and are accepted by Medicare are as follows:

The hemogram should be evaluated for any patient with signs, symptoms, or conditions associated with anemia or polycythemia. See Table 2 for specic signs, symptoms, and conditions.

The platelet count should be evaluated for patients with ndings or conditions associated with increased or decreased platelet production, destruction, or dys- function (Table 2). The platelet count is usually obtained as part of the hemo- gram.

The WBC differential should be evalu- ated for any patient with signs, symp- toms, or conditions associated with in- fections, inammatory processes, bone marrow alterations, and immune disor- ders (Table 2). The WBC count has also been recently identied as a possible risk stratication tool for mortality in acute coronary syndromes. 5

A hemoglobin and hematocrit (H&H) alone may be appropriate if there is only a need to assess the oxygen-carrying ca-

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GEORGE-GAY AND PARKER

Table 2. Signs, Symptoms, and Conditions That May Warrant a CBC or Parts of a CBC

Hemogram (Findings Related to Anemia)

Hemogram (Findings Related to Polycythemia)

Hemogram (Findings Related to Platelet Dysfunction)

WBC With Differential

Pallor Weakness Fatigue Weight loss Bleeding Acute or suspected blood loss from injury Hematuria Hematemesis Hematochezia Positive fecal occult Neuropathy Malnutrition Tachycardia Known malignancy Systolic heart murmur Congestive heart failure Dyspnea Angina Postural dizziness Syncope Nailbed deformities Known malignancy Jaundice Hepatomegaly Splenomegaly Lymphadenopathy Ulcers of the lower extremities

Fever Chills Ruddy skin Conjunctival redness Cough Wheezing Cyanosis Clubbing of the fingers Orthopnea Heart murmur Headache Memory changes Sleep apnea Weakness Pruritus Dizziness Excessive sweating Massive obesity Gastrointestinal bleeding Paresthesias Myocardial infarction Stroke Thromboembolism Hepatomegaly Splenomegaly COPD Diastolic hypertension Congenital heart disease Transient ischemic attack Visual symptoms

Gastrointestinal bleed Genitourinary tract bleed Bilateral epistaxis Thrombosis Ecchymosis Purpura Jaundice Petechiae Fever Heparin therapy Suspected DIC Shock Preeclampsia Massive transfusion Recent platelet transfusion Cardiopulmonary bypass Renal diseases Hypersplenism Neurologic abnormalities Viral or other infection Thrombosis Exposure to toxic agents Excessive alcohol ingestion Autoimmunue disorders (SLE, RA) Hepatomegaly Splenomegaly Lymphadenopathy

Fever Chills Sweats Shock Fatigue Malaise Tachycardia Tachypnea Heart murmur Seizures Altered consciousness Pain such as headache Abdominal pain Arthralgia Odynophagia Dysuria Redness/swelling of skin soft tissue or joint Ulcers of skin or mucous membrane Gangrene Bleeding Thrombosis Pulmonary infiltrate Jaundice Diarrhea Vomiting Opportunistic infections as oral candidiasis Hepatomegaly Splenomegaly Lymphadenopathy

Abbreviations: COPD, chronic obstructive pulmonary disease; DIC, disseminated intravascular coagulation; SLE, systemic lupus erythematosus; RA, rheumatoid arthritis. Data from Centers for Medicare and Medicaid Services (CMS). Available at www.cms.hhs.gov/ncd/searchdisplay.asp?NSD_ID 61&NCD_vrsn_num 1.

pacity of blood before surgery for pa- tients who do not have the previously listed signs, symptoms, or conditions (Table 2). The H&H may be helpful in the intraoperative and postoperative phase of care to assess and track for blood loss but can be misleading because of the intercompartmental uid shifts that occur during surgery and because of the dilutional effects of crystalloid ther- apy.

Specic perianesthesia indications for the CBC also take into account the level of surgical com-

plexity for a given procedure. In general, minor procedures are those with very low risk of large uid shifts or signicant blood loss. Minor pro- cedures include soft tissue and eye procedures; minor ortho; as well as ear, nose, and throat and urologic procedures, among others. Keep in mind that a minorprocedure may turn into a moderately complexprocedure as complica- tions are identied or develop. Major proce- dures are those that are often prolonged, often with high risk of large uid shifts or signi- cant blood loss. They often involve major body cavities. These include major abdominal, vascu-

UNDERSTANDING THE CBC WITH DIFFERENTIAL

Table 3. Levels of Surgical Complexity

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Level 1

Minimal risk to the patient independent of anesthesia

Minimally invasive procedures with little or no blood loss

Often performed in an ofce setting with the operating room principally for anesthesia and monitoring

Includes breast biopsy, removal of minor skin or subcutaneous lesions, myringotomy tubes, hysteroscopy, cystoscopy, beroptic bronchoscopy Level 2

Minimal to moderately invasive procedure

Blood loss less than 500 mL

Mild risk to patient independent of anesthesia

Includes diagnostic laparoscopy, dilatation and curettage, fallopian tubal ligation, arthroscopy, inguinal hernia repair, laparoscopic lysis of adhesions, tonsillectomy/adenoidectomy, umbilical hernia repair, septoplasty/rhinoplasty, percutaneous lung biopsy, extensive supercial procedures Level 3

Moderate to signicantly invasive procedure

Blood loss potential 500 to 1,500 mL

Moderate risk to patient independent of anesthesia

Includes hysterectomy, myomectomy, cholecystectomy, laminectomy, hip/knee replacement, major laparoscopic procedures, resection/reconstructive surgery of the digestive tract; excludes open thoracic or intracranial procedures Level 4

Highly invasive procedure

Blood loss greater than 1,500 mL

Major risk to patient independent of anesthesia

Includes major orthopedic-spinal reconstruction, major reconstruction of the gastrointestinal tract, major vascular repair without postoperative ICU stay Level 5

Highly invasive procedure

Blood loss greater than 1,500 mL

Critical risk to patient independent of anesthesia

Usual postoperative ICU stay with invasive monitoring

Includes cardiothoracic procedure; intracranial procedure; major procedure on the oropharynx; major vascular, skeletal, neurologic repair

lar, cardiothoracic, orthopedic, gynecologic/ urologic, head and neck, and neurologic proce- dures. Levels of surgical complexity from level 1 (minor) to level 5 (major) are described in Table 3. The American Society of Anesthesiologists(ASA) physical status classication system is an- other tool that can be used to assess the pa- tients current health status and overall periop- erative risk (Table 4). Although imprecise, it is a way to predict the patients anesthetic/surgical risks. The higher the ASA class, the greater the risks.

For the patient who is asymptomatic and active with a reliable benign history and undergoing a minor procedure, an H&H assessment may be all that is necessary or may not be indicated at all. For those patients undergoing major proce- dures, a CBC with platelets should be com- pleted. The CBC is indicated for elderly patients

( 65 years of age) as part of their preoperative assessment because of the comorbidities associ- ated with this age group as it may uncover clinical problems that were not picked up on physical examination. 6 Patients classied with an ASA score of 3 or greater should have a CBC before their surgical procedure. In addition to the general indications for CBC in Table 2, situations requiring a CBC before a surgical procedure are listed in Table 5.

Optimally efcient testing entails consideration of a combination of factors including the age, gender, and reliability of the patient; the surgi- cal procedure; and the type of anesthesia being used. Older or less reliable patients may be more likely to have an unsuspected abnormality picked up by a screeningtest. Major proce- dures are associated with signicant physiologic stress. Existing medical conditions, which may

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Table 4. ASA Classification

GEORGE-GAY AND PARKER

Class

Description

Examples

1

A normal healthy patient with no systemic illness

Healthy with good exercise tolerance Well-controlled hypertension, diabetes, without systemic effects; no evidence of COPD, anemia, or obesity Controlled heart failure, stable angina, or history of myocardial infarction; diabetes with systemic sequela; uncontrolled hypertension; morbid obesity Unstable angina, symptomatic heart failure, renal failure requiring dialysis

2

A patient with well-controlled systemic illness, but without functional restrictions

3

A patient with signicant degree of systemic effects that limits activities

4

A patient with severe systemic illness associated with signicant dysfunction and a constant potential threat to life

5

A patient in critical condition, who is at substantial risk of death within 24 hours with or without operative procedure

Multiple organ dysfunctions, hemodynamically unstable sepsis, poorly controlled coagulopathy

6

A patient declared brain dead undergoing organ removal for donor purposes

E

This symbol is added to any of the above classes to designate an emergency

Data

from

www.asahq.org,

www.nurse-anesthesia.com/generalanesthesia.htm,

and

www.vh.org/adult/provider/anesthesia/proceduralsedation/

asapatientclassification.html. Accessed December 2002.

be of little concern during a brief and minor procedure, may cause problems during and af- ter a long and complex surgery. Preoperative evaluation should reect this need for an in- creased level of preparedness and monitoring.

Timing of the CBC

A CBC completed within 2 months of a proce- dure is acceptable unless a change is suspected as a consequence of disease, medication, or treatment. Repeat testing is indicated for abnor- mal results or for patients with normal results who have conditions in which there is a con-

Table 5. Situations Requiring Preoperative CBC Evaluation

Abnormal bleeding ( platelets)

Heavy ETOH use ( platelets)

Potentially toxic medications (eg, which cause bone marrow depression)

Infection ( differential)

ASA score of 3

Vascular surgery

Anticipate prosthetic device or hardware placement

Anticipate 500 mL blood loss, invasive monitoring, or ICU ( platelets)

Level 4 or 5 surgery

Abbreviation: ETOH, alcohol.

tinued risk for the development of hematologic abnormalities.

Blood

The average adult has approximately 5.5 L of blood, consisting of plasma and cells. Plasma makes up 55% of the blood components and consists of proteins, water, and some waste products. Cells, of which there are 3 main types, make up the other 45%. They consist of (1) WBCs (leukocytes), of which there are sev- eral subtypes; (2) RBCs (erythrocytes); and (3) platelets (thrombocytes).

All blood cells are produced in the bone mar- row from a mother cell called the pluripotential (multipotential) stem cell (PSC). This PSC un- dergoes stages of differentiation until it be- comes committed to either the erythrocyte, thrombocyte, or one of the leukocyte subtypes (Fig 1). Under normal conditions, only mature blood cells should be found circulating in the blood. Alterations in the production and func- tion of these blood cells provide information about the patients diagnosis, prognosis, re-

UNDERSTANDING THE CBC WITH DIFFERENTIAL

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UNDERSTANDING THE CBC WITH DIFFERENTIAL 101 Fig 1. Blood cell differentiation. Reprinted with permission from Garrett.

Fig 1.

Blood cell differentiation. Reprinted with permission from Garrett. 16

sponse to therapies, and their recovery. The laboratory procedure that gives us this informa- tion is the CBC.

Obtaining the Blood Sample

The blood sample is obtained via venipuncture and is collected in a lavender top tube, which is the nationally accepted color standard. The blood sample will remain useable for analysis at room temperature for up to 10 hours, after which time the sample deteriorates and is not to be considered reliable. The blood sample can also be kept refrigerated and remain useable for as long as 18 hours. The sample should never be frozen. The patient should ideally be at rest for 10 to 15 minutes before obtaining the sample. Automated electronic devices perform enumer- ation of the blood cells. Blood cell counts are reported per microliter. Morphology is deter- mined by stained smears.

The WBC Count With Differential

The WBC count with differential determines the total number of WBCs (also called leuko- cytes) with a percentage of each type. The major function of the WBC is to defend the body against organisms and injury. WBCs are the main players in infectious/inammatory and immune responses. To appreciate the role of the WBC, a brief review of inammation/infec- tion and immunity is provided.

Inflammation and Infection

The inammatory process is triggered by cell injury, which can be caused by a variety of conditions such as trauma, burns, ischemia, sur- gery, snakebite, caustic chemicals, and ex- tremes in heat and cold, as well as infectious microorganisms. It is important to remember that although all infections are accompanied by inammation, not all inammation is accompa-

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nied by infection. In the perianesthesia setting, surgical incisions would be the most common trigger of inammation.

Any damage to the vascular endothelium or the mast cell will trigger an inammatory response, which is orchestrated by inammatory cyto- kines. Cytokines are hormonelike protein medi- ators responsible for the cell-to-cell commu- nication that regulates local and systemic physiologic and pathologic interactions. The cells of the vascular endothelium have been recently identied as a major player in the inammatory process.

The mast cell (cellular bag of granules) is an- other important activator of the inammatory response. Mast cells are found in connective tissues intimately surrounding blood vessels and in mucosal surfaces. Once endothelial or mast cells are injured or damaged, they release in- ammatory cytokines, which orchestrate the manifestations of inammation.

Manifestations of inammation include a short period of vasoconstriction to limit bleeding fol- lowed by vasodilation. Vasodilation increases blood ow to the area, bringing nutrients and large amounts of WBCs. Vasodilation also re- sults in hyperemia (redness and warmth). An- other manifestation is increased capillary per- meability, which allows for the immigration of WBCs from the blood vessel to the interstitial spaces where they can phagocytize unwanted organisms and debris. The WBCs also release cytokines to call more WBCs to the area and to perpetuate the inammatory response. In- creased capillary permeability also allows for the exudation of plasma and plasma proteins resulting in edema. The edema may cause pres- sure on the nearby nerves resulting in pain.

Immunity

In the immune process, specic types of WBCs respond to specic microorganisms. Immunity can be classied as either cell mediated or hu- moral. Cell-mediated immunity involves spe- cic types of WBCs called T lymphocytes or T cells. These T cells will attack host cells within

GEORGE-GAY AND PARKER

tissue that have been infected by microorgan- isms, as well as cancer cells. Cell-mediated im- munity provides primary defense against vi- ruses, fungi, slow-growing bacteria, and tumors.

Humoral immunity or antibody-mediated im- munity involves the production of antibodies by B cells and mainly occurs in body uid such as plasma and lymph. Humoral immunity pro- vides primary defense against bacteria. Cell-me- diated immunity is initiated frequently rst, but both cell-mediated and humoral immunity can be initiated simultaneously. Both types of immu- nity require specic types of WBCs to be effec- tive.

White Blood Cells

Although the medical term for the WBC is leu- kocyte, the term WBC will be used in this article for the sake of simplicity. WBCs can be divided into 2 main groups: phagocytes and immuno- cytes. Phagocytes are WBCs that have the capa- bility to attach to, engulf, and release enzymes to kill and degrade unwanted microorganisms and debris. The WBCs that are phagocytic in- clude neutrophils, eosinophils, basophils, and monocytes. Immunocytes include the lympho- cytes, WBCs that drive the immune response.

A more common manner in which WBCs are

divided is by the presence of granules in the cytoplasm. Those WBCs that contain granules

in their cytoplasm are neutrophils, eosinophils,

and basophils. WBCs that do not contain gran- ules in their cytoplasm include monocytes and lymphocytes (Fig 2). For the purpose of this discussion, WBCs will be divided into granulo- cytes and nongranulocytes.

Granulocytes

Granulocytes get their name from the granules present in their cytoplasm. These granules con- tain biochemical mediators that serve inamma- tory and immune functions. Granulocytes also contain enzymes in their cytoplasm capable of destroying microorganisms and catabolizing de- bris ingested during phagocytosis. They take about one week to develop in the bone mar-

UNDERSTANDING THE CBC WITH DIFFERENTIAL

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UNDERSTANDING THE CBC WITH DIFFERENTIAL 103 Fig 2. Granulocytes and nongranulocytes. Reprinted with permission from

Fig 2.

Granulocytes and nongranulocytes. Reprinted with permission from Catalano. 8

row. They circulate for only about 6 to 12 hours in the blood stream and 2 to 3 days after enter- ing the tissue.

Neutrophils

Neutrophils are a type of granulocyte and are mature cells that account for more than half of all the WBC subtypes in circulation. They are also called segmented neutrophils (segs) or polymorphonuclear neutrophils (PMNs) or polys because the nucleus of these cells consists of 3 to 5 lobes connected by thin strands. Highly motile, these cells are the rst to arrive (usually within 90 minutes) in response to acute inammation or infection; they migrate out of the capillaries and into the inamed tissue site in a process called diapedesis or emigration. The neutrophils ingest microorganisms and de- bris and then die, forming purulent exudate, which is removed by the lymphatics or through the epithelium.

When there is an increased demand for neutro- phils, as in response to acute infection, imma- ture neutrophils may be released from the bone marrow. These immature cells have unseg-

mented nuclei that resemble bands or rods. Thus, immature neutrophils are called bands or stabs. They are normally found only in very low percentages in circulating blood.

Eosinophils

Eosinophils function principally to ingest and kill multicellular parasites. They are also effec- tive in detoxifying antigen-antibody complexes that form during allergic reactions. People with chronic allergic conditions such as atopic rhini- tis and extrinsic asthma typically have elevated circulating eosinophil counts. Eosinophils are believed to play a role in downregulating hyper- sensitivity responses by neutralizing histamine, inhibiting mast cell degranulation, and inactivating slow-reacting subtances (SRS) of anaphylaxsis.

Basophils

Basophils are associated with systemic allergic reactions. Similar to mast cells, basophils have granules that contain proinammatory chemi- cals such as histamine, serotonin, bradykinin, and heparin. They release their granules in re- sponse to stimulation by immune cells. Ba- sophils circulate in the blood stream, whereas

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mast cells are found in connective tissue. The average basophil has a life span of days, but the mast cell can live weeks to months.

Nongranulocytes

Nongranulocytes, as mentioned earlier, are WBCs that do not have granules in their cyto- plasm. Inclusive in this group are monocytes and lymphocytes.

Monocyte/Macrophage

Monocytes are the largest of the WBCs and are young cells found freely circulating in blood or en route to a tissue location. Once the young monocyte leaves the blood stream and enters tissue, it transforms into a mature macrophage. Macrophages live within tissue spaces in wide- spread locations. These cells have different names related to the particular tissue in which they are found, ie, the Kupffer cells are macro- phages that live in the liver. Because of the complex connection of these cells to the blood stream and the tissue, monocytes and macro- phages are described as one system, called the mononuclear phagocyte system. Table 6 iden- ties specic macrophages and the particular tissue in which they are found.

Macrophages arrive on the scene in about 5 hours after injury and become the predominant leukocyte within 48 hours. Because macro- phages lie within the tissue spaces, they are usually the rst cell to engulf and process the antigen and present it to the immune cells (lymphocytes) in a manner that will stimulate a specic immune response to that particular an- tigen. In other words, the macrophage, in a special process, can destroy the organism while keeping its cell surface markers to give to the lymphocytes so that they can always identify that particular organism and mount a specic defense against it.

Lymphocytes

Lymphocytes are also nongranulocytes and are responsible for immune responses to specic organisms. They are the most numerous circu- lating WBC after neutrophils. There are 2 major

GEORGE-GAY AND PARKER

Table 6. Mononuclear Phagocyte System

Macrophage

Tissue

Kupffer cells

Liver

Alveolar macrophage

Lung

Histocytes

Connective tissue

Pleural and peritoneal macrophages

Serous cavities

Microglial cells

Nervous system

Osteoclasts

Bones

Mesangial

Kidneys

Langerhans

Skin

Dendritic cells

Lymphoid tissue

classes of lymphocyte: the T lymphocyte (T cell) and the B lymphocyte (B cell). Both T and

B cells can be sorted into subtypes based on

characteristic surface molecules on them called cluster of differentiation (CD). Cluster of differ- entiation surface molecules assist in dening the function of the different lymphocyte sub- types.

T cells. The T cell matures in the thymus and

is responsible for cell-mediated immunity as

previously described. The T cell can also stim- ulate the B cell, triggering humoral/anti- body-mediated immunity (also previously de- scribed). The T cell has several subtypes that can be divided into regulator or effector cells.

Regulator T cells are so called because of their regulatory functions of turning on or off the immune response. There are 2 types of regula-

tor T cells: the helper T cell and the suppressor

T cell. The helper T cell is considered the

master switch of the immune system. These cells are surveyors, and when a specic antigen

is presented to them, they release mediators

that inuence and stimulate the production of other immune cells including B cells. Helper T cells have CD4 surface molecules on them. Suppressor T cells suppress the immune re- sponse once the infection is controlled.

Effector cells are T cells that have a direct action. The 2 types of effector cells are the cytotoxic T cell and the memory T cell. The cytotoxic T cell carries the CD8 molecule on its surface. It attaches to identied infected

UNDERSTANDING THE CBC WITH DIFFERENTIAL

cells and cancer cells and releases enzymes to destroy these cells. Cytotoxic T cells are par- ticularly effective at destroying virally in- fected cells, foreign cells, and mutant cells. 7 Memory T cells are produced after invasion by a specic organism. They provide long- lasting immunity against that particular organ- ism and then wait to rapidly respond to a second attack by the same organism. Their average survival rate is about 5 years.

B cells. The B cell matures in the bone mar- row and is responsible for humoral, also known as antibody-mediated, immunity. When an anti- gen (foreign body) is presented to the B cell, either by a macrophage or helper T cell, the B cell becomes activated to produce plasma cells. The plasma cell then releases antibodies spe- cic for that specic antigen.

Natural killer cells. There is a third class of lymphocyte that does not have T- or B-cell markers called natural killer (NK) cells. NK cells are nonspecic and can therefore re- spond to a variety of antigens. They are very effective against tumor cells and virally in- fected host cells.

Evaluating the WBC Count With Differential

The white count differential is expressed in cubic millimeters and in percentages. See Table 7 for normal values of the differential.

Elevated Counts/Levels

An elevation in the total WBC count (WBC 11,000/ L) is called leukocytosis. Leukocyto- sis most commonly identies infection, tissue inammation, or tissue necrosis associated with disorders such as acute myocardial infarction, burns, gangrene, leukemia, radiation exposure, extremes in heat or cold, or lymphoma. 8 A WBC count of greater than 10,000 has been associated with increased mortality rates in pa- tients with acute coronary syndromes and is now being used by some as a predictor of adverse outcomes in these patients. 5,9 The role of inammation in the pathogenesis of ischemic

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Table 7. Normal White Blood Cell Counts

Cell Type

Absolute ( L)

Differential (%)

Total WBC

4,500-11,000

100

Granulocytes

 

Neutrophils

3,000-7,000

60-70

Segmented

2,800-5,600

54-68

Bands

150-600

3-5

Eosinophils

50-400

1-5

Basophils

25-100

0-0.75

Nongranulocytes

 

Monocytes

100-800

3-7

Lymphocytes (Immunocytes)

1,000-4,000

25-33

T

cells

800-3,200

80*

B

cells

100-600

10-15*

Natural killer

50-400

5-10*

*Percent of total lymphocyte count.

stroke is also currently being studied. Patients with elevated WBC counts during the stroke event have been found to have a greater relative risk of subsequent ischemic stroke than did those with lower WBC counts. 10 Thus, an ele- vated WBC count is being looked at as a predic- tor of ischemic stroke. Severely elevated total WBC counts ( 100,000), as seen in leukemia, promotes circulatory sludging and increased blood viscosity. Venous thromboembolism (VTE) prophylaxis is required in these situa- tions. 11

Leukocytosis may also occur in response to physical and emotional stressors such as over- exertion, seizures, anxiety, anesthesia, and epi- nephrine administration. With stress leukocyto- sis, however, the WBC will return to normal within an hour. Certain medications such as corticosteroids, lithium, and -agonists may also cause leukocytosis.

In the preoperative setting, an elevation in the WBC count frequently causes postponement or cancellation of a surgical procedure for further evaluation. If the total WBC count is elevated, the differential and the patient should be evalu- ated and the surgeon and anesthesia provider notied. The patients medication record and recent history should also be closely reviewed to discriminate among stress leukocytosis, drug administration, recent ischemia, myocardial in-

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farction, or infection as possible causes. An evaluation of the differential will allow for fur- ther discrimination.

Neutrophilia

Neutrophilia is an increase in the total neutro- phil count (including both segs and bands). Because neutrophils account for greater than 96% of all granulocytes, neutrophilia may also be referred to as granulocytosis. It is the most common cause of elevated WBC count.

Neutrophilia is most commonly caused by an acute bacterial infection. Neutrophil counts will rise 4 to 6 hours after an invasion by microor- ganisms. If ndings do not suggest infection, a myeloproliferative disorder may be the cause. Myeloproliferative disorders include polycythe- mia vera and chronic myelocytic leukemia, which increases stem cell proliferation in the bone marrow. Elevations in neutrophil counts are also associated with obesity and cigarette smoking. Additionally, neutrophil counts can increase after the stress of surgery, but in this case, counts will quickly return to normal if no infection is present. 12

An elevation in segmented neutrophils is con- sidered a shift to the right.During tissue breakdown from injuries such as burns, arthri- tis, myocardial infarction, hemorrhage, or elec- tric shock, neutrophils are called in to clean up the damaged or dead cells. In this case, reserve mature neutrophils are called in, thereby in- creasing the neutrophil count without calling in the immature cells. A severely elevated neutro- phil count will be seen in certain pathologic conditions causing the neutrophils to become hypermature. Hypermature segmented neutro- phils are those in which nuclear segmentation is impaired, and there is an increased number of segments ( 5). This is seen in liver disease, Downs syndrome, and megaloblastic and per- nicious anemia.

An elevation in bands is referred to as a shift to the left,which means that there is an increased number of immature neutrophils released from

GEORGE-GAY AND PARKER

the bone marrow and circulating in the blood. This occurs in response to overwhelming infec- tion when the numbers of mature neutrophil reserves have been depleted. Clinically, the term shift to the left species an acute bacterial infection has depleted the normal reserves of mature neutrophils, and the bone marrow has had to resort to releasing immature ones.

Generally, a shift to the right can be considered a result of tissue damage or necrosis, whereas a shift to the left can be considered a result of an overwhelming infection. As mentioned earlier, however, an increased neutrophil count is the most common cause of an elevated WBC count. Although not common, the other types of WBCs can also give rise to an elevation in WBC count.

Eosinophilia

Eosinophilia identies an increase in the eosin- ophil count. This count has been found to increase with parasitic infections such as toxo- plasmosis and with infections by gastrointesti- nal parasites. Elevations have also been noted with bronchoallergic reactions such as asthma, allergic rhinitis, and hay fever. Eosinophilia has also been noted with skin rashes.

Basophilia

Basophila is the most uncommon cause of an elevated WBC count. Increased basophil counts have been found in patients with hypersensitiv- ities compared with the general population. These patients should have a thorough allergy history obtained before any surgical procedure.

Monocytosis

Monocytosis, or increased monocyte counts, occur late during the acute phase of infection and with chronic infections such as tuberculo- sis and subacute bacterial endocarditis (SBE). The patient with an elevated monocyte count should be evaluated for further evidence of these possible conditions before surgical proce- dures. Monocytosis also occurs with Hodgkins disease, multiple myeloma, some leukemias, and systemic lupus erythematosus.

UNDERSTANDING THE CBC WITH DIFFERENTIAL

Lymphocytosis

Lymphocytosis occurs in acute viral infections such as mononucleosis, cytomegalovirus, mea- sles, mumps, and rubella. Elevated lymphocyte counts will also be noted in patients during chronic infections and early in human immuno- deciency virus (HIV) disease. Severely elevated levels would be seen with chronic lymphocytic leukemia (CLL). 13

Decreased Counts/Levels

A decrease in the total WBC count ( 4,500/ L) is called leukopenia. Leukopenia re- sults from decreased production of total WBCs in the bone marrow or increased destruction of WBCs. Total counts will usu- ally fall with radiation therapy and chemo- therapy as the bone marrow is depressed. WBC counts fall to the lowest points 7 to 14 days after induction of most chemothera- peutic agents and will then begin to in- crease as the bone marrow normalizes. Pa- tients receiving chemotherapy should have their WBC counts closely monitored. If leu- kopenia is present, the patient should be closely evaluated and the surgeon and anes- thesia provider notied. Blood cultures, si- nus and chest x-rays, and urine and stool cultures may also be necessary. As with an elevated WBC count, an evaluation of the differential will allow for further discrimina- tion.

Neutropenia

Neutropenia is clinically dened as a neutrophil count of less than 2,000/ L. Again, keep in mind that the majority of all granulocytes (neu- trophils, eosinophils, and basophils) are neutro- phils, which account for greater than 96% of all granulocytes. Because of this, the terms granu- locytopenia (decreased granulocyte count) and neutropenia (decreased neutrophil count) are used interchangeably in the clinical setting. Neutropenia can occur with severe prolonged infections that exhaust the bone marrow sup- plies, where the production cannot keep up with the demand. It can also be because of increased destruction of WBCs that can occur

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with increased splenetic pooling and destruc- tion as seen in hypersplenism or splenomegaly. Additionally, a variety of drugs can cause neu- tropenia such as certain antimicrobials, non- steroidal anti-inammatory drugs, and some analgesics. Other drugs include certain tricyclic antidepressants, anticonvulsants, antithyroids, cimetidine, and antidysrhythmic agents. Pa- tients with counts of less than 2,000/ L may be unable to mount an adequate defense when challenged by infection. These patients should be protected from cross contamination and should not undergo surgical procedures when at all possible.

Severe neutropenia is dened as a neutrophil count of less than 500/ L. This is also referred to as agranulocytosis because a count this low is almost equivalent to not having any granulo- cytes at all. Neutrophil counts below 500/ L predispose the patient to serious bacterial infec- tion and opportunistic infections of the skin, mouth, pharynx, and lungs. As counts fall be- low 100, the chance of gram-negative and gram- positive sepsis and fungal infections increases dramatically.

Other Reductions

Reductions in eosinophil (eosinopenia) and ba- sophil (basopenia) counts are uncommon be- cause so few of these cells normally circulate in the blood. Monocytopenia is a rare occurrence but has been seen with glucocorticoid therapy, hairy-cell leukemia, and aplastic anemia. Lym- phopenia, a decreased lymphocyte count, oc- curs normally as a person ages. Lymphopenia is most signicant with HIV and acquired immu- nodeciency syndrome (AIDS). A CD4 count (remember the helper T lymphocyte has the CD4 marker on its surface) of less than 200 is one indicator of conversion from HIV to AIDS.

Nursing Implications

The perianesthesia nurse should keep in mind that the WBC count is a part of a larger picture. One must look at the whole patient and put all information into proper perspective. 14 Trends can help to identify truly abnormal ndings.

108

The surgeon and anesthesia provider should be notied for elevations in WBC count of greater than 11,000, or decreases less than 4,500. Rec- ognize that minor alterations may be a reec- tion of age. One must determine whether the patient has enough neutrophils to combat and protect from infection when counts are low.

Leukocytosis commonly signals infection, whereas leukopenia indicates bone marrow de- pression that may result from viral infections or toxic reactions. Be alert to signs and symptoms of infection, especially in patients with invasive lines, indwelling urinary catheters, surgical drains, and incision sites. General signs of infec- tion include fatigue, fever, a change in level of consciousness (LOC), dehydration, pharyngitis, or hypotension. More frequent temperature monitoring may be indicated.

Neutropenic precautions should be considered for severely immunocompromised patients and those with severe neutropenia. Neutropenic precautions include the following:

Meticulous care of all intravenous lines and indwelling catheters

Avoiding raw and uncooked foods, in- cluding fresh fruits and vegetables be- cause of microorganism contamination from soil

Avoiding crowds

Avoiding children who have just been vaccinated

Avoiding indiscriminate use of antipyret- ics

Avoiding steroid use, because they im- pede mediator functions blocking in- ammation; thus, the patient will not show the true signs of inammation or infection

Reporting a temperature greater than 38°C (100°F), chills, sore throat, dia- phoresis, or dysuria

Be suspect of the potential for septicemia in patients with a neutrophil count of less than 500/ L. Moving forward with any surgical pro-

GEORGE-GAY AND PARKER

cedure in patients with counts of less than 2,000/ L should be considered only for emer- gent situations. Also note that patients with WBC counts greater than 100,000 are at an increased risk for thrombosis because of in- creased blood viscosity. Ensure adequate uid intake and VTE prophylaxis. See Table 8 for recommendations regarding VTE prophylaxis in the surgical patient. Patients with recent ische- mic stroke or myocardial infarction, and a con- comitant elevation in WBC count may be at increased risk for mortality or morbidity.

Erythrocyte (RBC) Studies

The main function of the RBC is to carry oxygen (O 2 ), which it picks up in the lungs, to the cells of the body, and to transport carbon dioxide from the cell to the lungs for excretion. Essen- tially, RBCs are containers for hemoglobin (Hgb). Hgb is the oxygen-carrying protein of the RBC, which accounts for approximately 90% of the cellsdry weight. Information about the RBC is obtained with a CBC but can also be obtained separately with a hemogram.

RBCs are produced at a rate of 2 million cells per second, or 35 trillion cells per day. The average life span is approximately 120 days. The mature RBC is a biconcave disk. This unique shape allows for a greater surface area for oxy- gen to combine with Hgb. RBCs have no nu- cleus, and therefore cannot divide. Like the WBC, the RBC is derived from the PSC in the bone marrow (Fig 1). The production of RBCs by the bone marrow is stimulated by low oxy- gen levels in peritubular cells of the kidney in a process called erythropoiesis. During erythro- poiesis, renal erythropoietic factor (an enzyme) is secreted in response to peritubular cell hy- poxia. This factor interacts with a plasma pro- tein to form erythropoietin, a hormone that circulates to the bone marrow to stimulate stem cells to produce more RBCs. RBCs are released from the bone marrow as reticulocytes and then become mature RBCs in one day.

Vitamin B 12 , folic acid, and iron are also needed for RBC metabolism. Vitamin B 12 and folic acid

UNDERSTANDING THE CBC WITH DIFFERENTIAL

Table 8. Venous Thromboemolism Prophylaxis

109

Type of Surgical Procedure

Recommended Prophylaxis

General surgery Minor procedure without additional risk factors in patients less than 40 years of age Minor procedure with additional risk factors in patients less than 40 years of age Minor procedure in patients 40 to 60 years of age without additional risk factors Major surgery in patients without additional risk factors 40 years of age Nonmajor surgery with additional risk factors in patients 60 yr Major surgery in patients 40 yrs or with additional risk factors Major surgery in patients 40 with multiple risk factors Gynecologic surgery Major surgery for benign disease without additional risk factors Extensive surgery for malignancy

Low risk Early ambulation Moderate risk LDUH every 12 hours starting 1 to 2 hours before surgery LMWH rst dose generally before surgery ES or IPC device to start immediately before procedure and continue until fully ambulatory

High risk LDUH every 8 hours, LMWH, or IPC device

Very high risk LDUH, LMWH, combined with mechanical method (ES or IPC device)

LDUH twice a day, alternatively, LMWH or IPC device started just before surgery and continued at least several days postoperatively LDUH three times a day For additional protection use LDUH plus ES or IPC device

Urologic surgery Transurethral surgery or other low-risk procedure Major open urologic procedure Highest risk patients

Elective knee replacement

Prompt mobilization LDUH, ES, IPC device, or LMWH LDUH or LMWH and ES with IPC device

Orthopedic surgery Elective total hip replacement

LMWH started 12 hours before surgery, may be started 12 hours postoperatively; ES or IPC device should be added LDUH, aspirin, dextran, and IPC alone are not recommended LMWH or adjusted dose warfarin to maintain an INR of 2 to 3

IPC with or without ES

Hip fracture surgery Neurosurgery, trauma, & acute spinal cord injury Intracranial neurosurgery

Trauma

IPC is effective if used optimally; LDUH not recommended LMWH or adjusted dose warfarin

LDUH or LMWH postoperatively are alternatives with a concern about intracranial hemorrhage For high-risk patients the combination of mechanical and pharmacologic prophylaxis may be more effective LMWH started as soon as possible if no contraindications (risk of bleeding); if

Acute SCI

contraindicated start ES and/or IPC IVC lter is recommended if proximal DVT is seen and anticoagulation is contraindicated; IVC lter is not recommended for primary prophylaxis LMWH started as soon as possible; LDUH, ES, and IPC not recommended when used alone. ES and IPC may benet when used in combination with LMWH or LDUH, or if anticoagulants are contraindicated.

Medical conditions Acute myocardial infarction

Ischemic stroke

General medical conditions with risk factors

For most patients, prophylaxis with LDUH or therapeutic doses of IV heparin are recommended. LDUH, LMWH or the heparinoid, danaparoid; if anticoagulation is contraindicated, use ES or IPC device LDUH or LMWH

NOTE. Risk factors include previous VTE, increasing age, major surgery, cancer, obesity, major trauma, lower extremity or hip fracture, pregnancy, history of myocardial infarction, stroke, heart failure, hormone replacement therapy, prolonged immobilization, burns, paralysis, hypercoagulable states, indwelling femoral vein catheter, inammatory bowel disease. Abbreviations: LDUH, low-dose unfractioned heparin; LMWH, low molecular weight heparin; ES, elastic stocking; IPC, intermittent pneumatic compression; IFC, inferior vena cava; DVT, deep vein thrombosis; SCI, spinal cord injury. Data from Geerts WH, Heit JA, Clagett GP, et al: Prevention of venous thromboembolism, Sixth ACCP Consensus Conference on Antithrombotic Therapy. Chest 119:132s-175s, 2001, and Hirsh J: Managing venous thromboembolism: Methodology for achieving positive outcomes. CME-Today (Cardiopulmonary and Critical Care) 1:11-15, 2002.

110

are needed for cell growth, DNA synthesis, and for reproduction. Iron is needed for Hgb syn- thesis.

Several tests are done to determine the ade- quacy of the RBC structure and function, the RBC count, Hgb concentration, hematocrit (Hct), and RBC indices.

Erythrocyte (RBC) Count

The RBC count is the part of the CBC that determines the number of RBCs found in a cubic centimeter of blood. It is also expressed in International Units, which is the number of RBCs per liter of blood. Electronic automated devices perform the test. Although the total RBC count does give information about the oxygen-carrying capacity of blood, Hgb and Hct provide more precise information. See Table 9 for normal values.

Hemoglobin

As previously mentioned, Hgbs primary func- tion is to carry oxygen to the cells and remove carbon dioxide from the cells. Hgb is a complex protein made up of heme and globin. It is produced in the immature RBC. Synthesis stops once the cell matures in circulation. There are approximately 300 million molecules of Hgb in one RBC. Hgb is measured in grams per decili- ter. See Table 10 for normal values.

The heme portion contains iron atoms and the red pigment, porphyrin. The heme portion is responsible for the red color of blood. When the RBC is saturated with oxygen, the red color is brightest. The globin portion is made up of 4 amino acid chains. One heme molecule at- taches to each of the 4 amino acid chains. Therefore, each Hgb molecule has 4 heme sites that can bind with 4 oxygen molecules. A Hgb

Table 9. RBC Count

Conventional Units

SI Units

GEORGE-GAY AND PARKER

Table 10. Hemoglobin

Conventional Units

SI Units

Adult

male

13.5-18 g/dL

135-180 g/L

Adult

female

12-16 g/dL

120-160 g/L

is considered fully saturated when it contains 4 oxygen molecules. Hgb saturated with oxygen is called oxyhemoglobin. One should note that oxygen saturation is a measure of the amount of oxygen combined with Hgb in the blood and should not be confused with the partial pres- sure of oxygen (PO 2 ), which is the amount of oxygen dissolved in plasma. Hgb also functions as a buffer for extracellular uid and is capable of accepting hydrogen (H ) ions to prevent the buildup of H ions in the blood.

Hematocrit

Hct represents the percentage of the total vol- ume of RBCs relative to the total volume of whole blood in a sample. Hematocritmeans to separate blood.With todays method of automated cell counting, Hct is calculated rather than centrifuged. See Table 11 for normal values. The surgeon and anesthesia provider must be notied for values of less than 20% or greater than 60%. Swelling of the RBC secon- dary to hyperglycemia or hypernatremia may produce an elevated Hct. Excessively elevated WBC counts may also alter the Hct.

Hgb and Hct levels parallel, in that Hct levels are 3 times the Hgb level. To estimate values, you would divide the Hct by 3 to estimate the Hgb, and multiply the Hgb by 3 to estimate the Hct. This relationship is altered if RBCs are abnormal in size or shape or if the synthesis of Hgb is defective.

The RBC count, Hct, and Hgb are closely re- lated. Alterations in one are usually associated

Table 11. Hematocrit

Conventional Units

SI Units

Adult

male

4.6-6.2 million/ L

4.6-6.2 10 12 /L

Adult male

40%-54%

0.40-0.54

Adult

female

4.2-5.4 million/ L

4.2-5.4 10 12 /L

Adult female

38%-47%

0.38-0.47

UNDERSTANDING THE CBC WITH DIFFERENTIAL

with alterations in the other. As such, increases and decreases in each are discussed together.

Increased Levels

An increase in the number of RBCs can be described as either erythrocytosis or polycythe- mia. In the clinical setting, the terms are fre- quently used as synonyms. The term erythrocy- tosis, however, more accurately denes an elevated RBC count, whereas the term polycy- themia more accurately refers to a specic group of disorders. These disorders can be de- scribed as either primary polycythemia or sec- ondary polycythemia.

Primary polycythemia (vera) is an increase in the number of RBCs secondary to a relatively rare myeloproliferative disease of the bone mar- row involving the excessive production of red cell precursors. Secondary polycythemia de- scribes an increase in RBCs as a physiologic compensatory mechanism (via erythropoietin) for decreases in oxygen delivery as seen in cardiopulmonary diseases such as congestive heart failure (CHF), cardiovascular malforma- tion, and chronic obstructive pulmonary dis- ease, as well as in those living in high altitudes.

Dehydration also causes a relative increase in RBC, Hgb, and Hct because of a decrease in plasma volume. This is clinically referred to as hemoconcentration and may be seen frequently in the perianesthesia setting. Other causes in- clude excessive exercise, anxiety, pain, and cer- tain drugs such as gentamycin and methyldopa (Aldomet), as well as with renal and liver tu- mors.

Decreased Levels

Decreased levels of RBCs, Hgb, and Hct are associated with hemodilution and anemia. He- modilution occurs as plasma volume increases from uid therapy. Anemia is a reduction in the total number of circulating RBCs or a decrease in the quality or quantity of Hgb or in the volume of packed cells (Hct). Nutritional ane- mias or anemias caused by chronic diseases are caused by iron, folate, and vitamin B 12 decien-

111

cies. Acute anemias are caused by blood loss due to hemorrhage, or by RBCs being destroyed faster than the normal bone marrow can re- place them. Extreme RBC destruction occurs in conditions such as hemolytic or type II hyper- sensitivity blood transfusion reactions (hemoly- sis of RBCs because of ABO incompatibility). Other conditions causing anemia are those that alter erythropoiesis such as renal failure, chemo- therapeutic agents (by suppressing the bone marrow), and leukemia. Hemoglobinopathies (such as sickle cell anemia) and the thalassemias are also causes of anemia. Age also plays a role in anemia because there is a tendency for lower values in people over the age of 50. Lastly, during pregnancy there is a relative anemia as the normal number of RBCs becomes diluted from the increase in body uid that occurs during pregnancy.

Although all types of anemia will be seen in the perianesthesia setting, the most common cause of decreased RBC, Hgb, and Hct levels overall is blood loss or hemorrhagic anemia. Red cell transfusion is almost always indicated for a Hgb less than 6 g/dL and rarely indicated for Hgb greater than 10 g/dL. Once the Hgb level falls below 11 g/dL in an otherwise healthy adult, the kidney will begin to secrete increasing amounts of erythropoietin in a matter of hours. Unfortunately, it will take 3 to 6 days before a rise in circulating RBCs will be noted. However, the decision to transfuse should never be dic- tated by a single Hgb trigger. 15

Other RBC Values

Reticulocyte Count

The reticulocyte is an immature RBC found in the bone marrow (Fig 1). There is a small per- centage of reticulocytes released into the blood stream that accounts for approximately 0.5% to 1.5% of the total RBC count. An increased count indicates the bone marrow is attempting to replace sudden RBC loss from hemorrhage or destruction. A decreased count would indicate bone marrow hypofunction. This count is nor- mally increased in pregnancy.

112

 

Table 12. RBC Indices

 

Conventional Units

SI Units

Adult

MCV

82-93 m 3

82-93 fL

MCH

26-34 pg

1.61-2.11 fmol

MCHC

31-38%

19.2-23.58 mm/L

RBC Indices

RBC indices are calculated mean values that are used to dene the size, weight, and Hgb con- tent of the RBC. They are mainly used to classify anemias. RBC indices consist of mean corpus- cular volume (MCV), mean corpuscular hemo- globin (MCH), and mean corpuscular hemoglo- bin concentration (MCHC). See Table 12 for normal values.

Mean corpuscular volume. MCV describes the RBC by size or volume. This measure uses the size of the RBC to identify possible causes of anemia as well as other disorders. The MCV classies RBCs as microcytic, normocytic, and macrocytic. Microcytic cells are small or un- dersized. They are seen with iron deciency anemia and thalassemia. In hemorrhagic or hemolytic anemias, the decrease in oxygen- carrying capacity is caused by a decrease in the number of RBCs; the cells that remain are normal in size, thus the RBCs are normocytic. RBCs that are macrocytic are large or over- sized. These RBCs are seen in patients with pernicious or folate deciency anemia. MCV is a calculated value obtained by dividing the Hct by the RBC count.

Mean corpuscular hemoglobin. This value is the index that measures the average weight of Hgb in the RBC. An alteration in MCH tends to track along with the MCV. For example, a small- sized cell will have less Hgb within it compared with a large-sized cell, therefore its weight would be lower. Decreases are related to micro- cytic anemias, and elevations are related to mac- rocytic anemias. Therefore, the MCH adds little information independent of the MCV.

GEORGE-GAY AND PARKER

Mean corpuscular hemoglobin concentra- tion. This index is a measure of the average concentration of Hgb in the RBC per unit volume. RBCs that contain less Hgb are hypo- chromic and are a pale color. Normal-colored cells with normal amounts of Hgb are called normochromic, and hyperchromic cells have an increased concentration of Hgb and are bright red in color. 16

Nursing Implications

Polycythemic patients need to be monitored for signs and symptoms of thrombus formation. Patients should be monitored closely for com- plaints of leg pain, changes in color, tempera- ture, and capillary rell in addition to initiating VTE prophylaxis (Table 8) and ensuring ade- quate uid administration. Sudden restlessness, anxiety, and dyspnea may herald a pulmonary embolus. Changes in a patients level of con- sciousness or neurologic examination can warn of diminished cerebral blood ow and warn of the potential for stroke.

Anemic patients are at additional risk anytime they must undergo surgical procedures. Be sure to request a type and crossmatch to ensure that patient-compatible blood will be available in the blood bank. Be alert to signs of blood loss, including but not limited to hypotension, tachy- cardia, restlessness, hypoxia, chest pain, fa- tigue, and occult blood positive stools and gas- tric specimens. In the preanesthesia setting, the decision to transfuse the patient with Hgb be- tween 6 and 10 g/dL should be based on indi- vidual risk, such as type and extent of the surgery, the ability to control the bleeding, and the rate of uncontrolled bleeding. For elective procedures, Hgb of 10 g/dL or greater is recom- mended. Preoperative Hgb below 10 g/dL is an indication to postpone an elective case. If blood transfusion is required, expect the Hgb to rise by 1 g and the Hct by 3% for each unit of packed RBCs transfused.

Patient care activities may need to be delivered in such a way as to reduce the patients fatigue, metabolic demand, and physical stress. Contin-

UNDERSTANDING THE CBC WITH DIFFERENTIAL

uous pulse oximetry is required to monitor for hypoxia. Be prepared to provide supplementary oxygen and to promote adequate lung expan- sion through optimal patient positioning. Also use pulmonary hygiene strategies and teach pa- tients to perform turn, cough, and deep breath exercises.

Closely monitor intake and output in patients with Hgb counts below 7 to 8 g/dL. Blood ow to the kidneys is diminished in these states, and the patient is at risk for oliguria. Secure and maintain intravenous access for these patients. Additionally, provide passive or active warming measures because patients will complain of cold and be pale in color.

RBC indices assist in classifying anemias. In general, be sure to fully assess a patients nutri- tional status and consult a dietitian for further workup and intervention as appropriate. Wound healing can be grossly affected by nu- tritional anemias, and patients may require iron, zinc, and vitamin C supplements to promote surgical wound healing. Patients will also re- quire teaching and need encouragement to in- clude iron-rich foods such as liver, red meat, raisins, peas, apricots, kidney beans, and forti- ed cereals and breads in their diets.

Increased RBC indices indicate an increased number of circulating immature RBCs in the peripheral circulation, increasing the patients likelihood of jaundice, stomatitis, and glossitis. Attention to mouth care will be essential. The use of soft bristle toothbrushes and cool, alka- line mouthwash is recommended. The patient should be informed to avoid sour, tart, and spicy foods, as well as foods that are extremely cool or hot in temperature. Jaundiced patients will require comfort measures and medications to reduce the discomfort associated with itching.

Platelets (Thrombocytes)

Platelets are the smallest of the cells found in blood. They are nonnucleated, attened disk- shaped structures that can be round or oval. They have a lifespan of 9 to 12 days.

113

Platelets play a vital role in hemostasis; they, along with the coagulation factors, are respon- sible for hemostasis in small and medium-size arteries and veins. Platelets aggregate or stick together to form the initial plug where there is damaged endothelium. Clotting factors are then triggered to form brin strands throughout the plug to rmly hold the plug together. For the capillaries, platelets plug and stop bleeding by themselves, thereby sealing the multitude of minute ruptures that occur on a daily basis. A platelet plug forms within 3 to 5 minutes.

The platelet count only provides the number of circulating plates; it does not describe how adequately they function. The most indicative test of platelet function is the bleeding time.

Increases in the platelet count or thrombocyto- sis are usually asymptomatic until counts reach greater than 1,000,000 /L, where increased viscosity and inappropriate clotting may occur.

A transient thrombocytosis with platelet counts

of 450,000 to 600,000 /L can be seen as a physiologic response to physical stress, exer- cise, trauma, infection, and ovulation. Counts

greater than 600,000 /L may be associated with myeloproliferative disorders of the stem cells in the bone marrow.

Thrombocytopenia or decreased platelet count

is dened as a count of less than 150,000 /L.

Causes include depressed production by the bone marrow or increased consumption or de- struction as seen with idiopathic thrombocyto- penia. Bleeding usually does not occur until counts fall below 50,000 /L if platelets are functioning normally. Small hemorrhagic areas under the skin called purpura may occur at this level.

Nursing Implications

Patients with known thrombocytopenia are at risk for bleeding, especially when counts fall below 50,000 /L. Counts under 20,000 /L signicantly increase the risk for mortality sec- ondary to hemorrhagic stroke or gastrointesti- nal hemorrhage. 16 In these instances, consider

114

GEORGE-GAY AND PARKER

advocating for the postponement of surgical procedures and prepare for possible plate- let transfusion. Platelet transfusion is recom- mended prophylatically for the surgical patient with a platelet count of less than 50,000 /L who is undergoing a major procedure. Platelet transfusion may also be indicated if there is known platelet dysfunction and microvascular bleeding despite adequate counts. 16 For each concentrate of platelets transfused, expect the platelet count to increase by 5,000 to 10,000 /L. Keep in mind that one aspirin will coat the platelet, preventing it from aggregating for the life of that platelet. A preoperative aspirin may be more important than platelet count in ex- plaining a bleeding disorder.

Remember that thrombocytosis commonly oc- curs after hemorrhage and surgical procedures.

Counts soon return to normal limits once the patient recovers from the primary insult. The need for VTE prophylaxis (Table 8) for patients with increased platelet counts also exists. Pa- tient teaching should include precautions to minimize the risk for infection and bleeding in postsurgical recovery period.

Summary

It is clear that the needs of patients in the perianesthesia setting are driven by the context of their respective surgical treatment plans. These needs become complex when integrated with the magnitude of premorbid conditions and drug proles that exist for each individual patient. Knowledge of a patients premorbid state and medications should heighten the cli- niciansawareness and analysis of specic CBC and differential results.

References

1. Chernecky C, Berger BJ (eds): Laboratory Tests and Diag-

nostic Procedures (ed 3). Philadelphia, PA, Saunders, 2001, pp

372-376

2. Centers for Medicare and Medicaid Services (CMS): Na-

tional Coverage Determinations for Blood Counts. Available at www.cms.hhs.gov/ncd/searchdisplay.asp?NCD_ID 61&NCD_ vrsn_num 1. Accessed December 2002.

3. Goodnough LT, Brecher ME, Katner MH, et al: Transfusion

medicine: Blood transfusion. N Engl J Med 340:438-447, 1999

4. Medicare Part B Model Local Medical Review Policy, Sub-

ject: Blood counts. Avera Health Lab News. 4:2-4, 2000. Available at www.averalabnet.com/newsletters/NewsJanFeb00.htm. Ac- cessed December 2002

5. Cannon CP, McCabe CH, Wilcox RG, et al: Association of

white blood cell count with increased mortality in acute myo- cardial infarction and unstable angina pectoris. Am J Cardiol 87:636-639, 2001

6. Baylor College of Medicine: Geriatric assessment, medical

assessment, laboratory work-up. Available at www.geri-ed. com/modules/Asses/assess/medical_assessment.htm. Accessed December 2002

7. Banasik JL: Inammation and Immunity, in Copstead LC,

Banasik JL (eds): Pathophysiology Biological and Behavioral Per- spectives (ed 2). Philadelphia, PA, Saunders, 2000, pp 184-218

8. Catalano P: White blood cell count with differential, in

George-Gay B, Chernecky C (eds): Clinical Medical-Surgical Nursing. Philadelphia, PA, Saunders, 2002, pp 282-290

9. Sadovsky R: WBC predicts increased mortality in acute

MI. Am Fam Physician 64:1261, 2001

10. Koch-Kubetin S: WBC Count Predicts Stroke. OB GYN

News. 25:24, 2000

11. Tresler KM: Hematology screen, in Clinical Laboratory

Diagnostic Tests Signicance in Nursing Implications (ed 3).

Norwalk, CT, Appleton Lange, 1995

12. Abramson N, Melton B: Leukocytosis: Basics of clinical

assessment. Am Fam Physician 62:2053-2060, 2000

13.

Gawlikowski J: White cells at war. Am J Nurs 92:44-51,

1992

14.

The ABCs of CBC: A common blood test. Mayo Clinic

Health Letter, August 2001, pp 4-5

15. American Society of Anesthesiologists: Practice Guide-

lines for Blood Component Therapy. Available at www.asahq.

org/practice/blood/blood_component.html. Accessed December

2002

16.

Garrett K: Red blood cell counts, in George-Gay B,

Chernecky C (eds): Clinical Medical-Surgical Nursing. Philadel- phia, PA, Saunders, 2002, pp 274-282

UNDERSTANDING THE CBC WITH DIFFERENTIAL

115

Understanding the Complete Blood Count With Differential 1.4 Contact Hours

Directions: The multiple-choice examination below is designed to test your understanding of the Complete Blood Count With Differential according the objectives listed. To earn contact hours from the American Society of PeriAnesthesia Nurses (ASPAN) Continuing Education Provider Program: (1) read the article; (2) complete the posttest by indicating the answers on the test grid provided; (3) tear out the page (or photocopy) and submit postmarked before February 28, 2005, with check payable to ASPAN (ASPAN member, $12.00 per test; nonmember, $15.00 per test); and (4) return to ASPAN, 10 Melrose Ave, Suite 110, Cherry Hill, NJ 08003-3696. Notication of contact hours awarded will be sent to you in 4 to 6 weeks.

Posttest Questions

1. In the process of erythropoiesis, iron is needed for

a. hemoglobin synthesis.

b. DNA synthesis.

c. reproduction.

d. renal excretion.

2. When monitoring a patient who is not bleeding, the nurse would expect to nd an increase in Hct of 3% after a transfusion of one unit of packed RBCs.

a. True

b. False

3. The amount of blood combined with Hgb is a measurement of

a. partial pressure of oxygen (PaO 2 ).

b. arterial-venous oxygen difference.

c. oxyhemoglobin.

d. oxygen saturation (SaO 2 ).

4. In an adult patient with normal Hgb, the nurse will estimate the Hgb to be 10 g/dL if the Hct was reported to be 30%.

a. True

b. False

5. Secondary physiologic polycythemia is caused by all of the following except

a. congestive heart failure.

b. renal failure.

c. high altitudes.

d. chronic obstructive pulmonary disease.

6. Pernicious anemia is caused by

a. alcoholism.

b. chronic blood loss.

c. vitamin B 12 deciency.

d. iron deciency.

7. An elevated reticulocyte count would be expected in

a. a recovering trauma patient who lost signicant amounts of blood.

b. a patient with a chronic inammatory disease.

116

c. a patient in renal failure.

d. a patient with bone marrow hypofunction.

GEORGE-GAY AND PARKER

8.

All of the following are included in the CBC except

a. erythrocyte sedimentation rate.

b. neutrophil count.

c. platelet count.

d. bands.

9.

A CBC is indicated for patients greater than age 65.

a. True

b. False

10.

Shift to the rightmeans that

a. there is an elevation in bands.

b. the patient probably has an acute viral infection.

c. an acute hypersensitivity reaction is occurring.

d. hypermature segmented neutrophils are present.

11.

Neutropenic precautions involves all of the following except

a. reverse isolation.

b. staying away from children recently vaccinated.

c. reporting temperatures of greater than 38°C.

d. avoiding indiscriminate use of acetaminophen.

12.

The major cell of the immune response is the

a. cytotoxic T cell.

b. B cell.

c. plasma cell.

d. helper T cell.

13.

Nutritional anemias as recognized in the RBC indices can assist in identifying patients

a. at risk for allergic reactions.

b. in need of postoperative blood transfusion.

c. at risk for poor wound healing.

d. none of the above.

14.

Once Hgb levels fall below 11 g in an otherwise healthy adult, the kidney will begin to

secrete erythropoietin in a matter of hours. A rise in circulating red blood cells will be noted within

a. 6 to 8 days.

b. 3 to 5 days.

c. 24 hours.

d. 48 hours.

15.

Venous thromboembolism prophylaxis is required for patients with total WBC counts greater than 100,000.

a. True

b. False

UNDERSTANDING THE CBC WITH DIFFERENTIAL

117

ANSWERS System W010405. Please circle the correct answer

1.

a.

2.

a.

3.

a.

4.

a.

5.

a.

b.

b.

b.

b.

b.

c.

c.

c.

d.

d.

d.

6.

a.

7.

a.

8.

a.

9.

a.

10.

a.

b.

b.

b.

b.

b.

c.

c.

c.

c.

d.

d.

d.

d.

11.

a.

12.

a.

13.

a.

14.

a.

15.

a.

b.

b.

b.

b.

b.

c.

c.

c.

c.

d.

d.

d.

d.

Please Print

 

Name

 

Nursing License No/State

 

Address

 

City

State

Zip

 

Social Security

 

ASPAN Member #

 

EVALUATION: Understanding the Complete Blood Count With Differential (SD, strongly disagree; D, disagree; ?, uncertain; A, agree; SA, strongly agree)

 

SD

D

?

A

SA

1. To what degree did the content meet the objectives?

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5

a. Objective #1 was met.

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2

3

4

5

b. Objective #2 was met.

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2

3

4

5

c. Objective #3 was met.

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2

3

4

5

d. Objective #4 was met.

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2

3

4

5

e. Objective #5 was met.

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2

3

4

5

f. Objective #6 was met.

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4

5

2. The program content was pertinent, comprehensive, and useful to me.

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5

3. The program content was relevant to my nursing practice.

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4. Self-study/home study was an appropriate format for the content.

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5

5. Identify the amount of time required to read the article and take the test. 25 min 50 min 75 min 100 min 125 min

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5

Test answers must be submitted before April 30, 2005, to receive contact hours.