The Power of the RBC

Indices

Letting Go of the Rules of Three

Objectives
• Discuss the history of the Rules of Three
and their original purpose in the
hematology testing.
• Explain the importance of the RBC Indices
and how they are better indicators of
problem samples.
• Apply your knowledge of the RBC Indices
to real life case examples.

THE RULES
OF
3
•WHAT THEY ARE
•WHERE THEY CAME FROM
•WHY THEY NEED TO GO AWAY

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 THE RULES OF 3

HGB X 3 = HCT +/- 3%

RBC X 3.3 = HGB +/- 1.5 gm/dl

RBC X 9 = HCT +/- 3%

OR…

RBC x 3 = HGB, HGB x 3 = HCT

ACTUALLY….THERE IS A 4TH
RULE

…..and it is

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 4TH RULE
THE RULES OF 3 ONLY WORK
WHEN THE RED CELLS ARE
NORMAL

( LIKE NORMAL SIZE AND NORMAL HGB

CONTENT)

SO IF THE RED CELLS ARE

NORMAL WHYARE WE
DOING RULES ?

WHERE THEY CAME FROM

A TIME LONG AGO…..

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4
 WINTROBE
1929 - TULANE

• NO ESTABLISHED NORMALS
• MOST ERRORS WERE IN THE RBC

WINTROBE
1929 - TULANE

• INVENTED A RELIABLE HCT

• DERIVED THE RELATIONSHIP OF

RESULTS = INDICES

WINTROBE INDICES or RBC INDICES

• Provide important information regarding

RBC size, HGB concentration, and HGB
weight – used primarily to categorize
anemias.

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 WINTROBE INDICES
‘reference range’
• MCV = (HCT/RBC) x 10 78 – 100

• MCH = (HGB/RBC) x 10 26 – 34

• MCHC = (HGB/HCT) x 100 32 – 36.5

AND THUS….

A RELATIONSHIP BETWEEN RESULTS

WAS BORN

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 WHAT THEY TOLD US
• RBCs WERE NORMAL, BIG, OR SMALL

• RED CELL HGB CONTENT WAS NORMAL,

INCREASED OR DECREASED

• WE MESSED UP

WINTROBE INDICES
‘reference range’
• MCV = (HCT/RBC) x 10 78 – 100

• MCH = (HGB/RBC) x 10 26 – 34

• MCHC = (HGB/HCT) x 100 32 – 36.5

(But who could do these in their head ?)

SO…BEFORE WE HAD INSTRUMENTS

THAT DID INDICES

WE MADE THE MATH EASIER

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 WINTROBE INDICES
AND
THE RULES OF 3

MCV = (HCT/RBC) x 10
RBC X 9 = HCT +/- 3%

MCH = (HGB/RBC) x 10
RBC X 3.3 = HGB +/- 1.5 gm/dl

MCHC = (HGB/HCT) x 100

HGB X 3 = HCT +/- 3%

WHY THEY SHOULD HAVE

GONE AWAY

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YOU KNOW WHEN YOU HAVE A PROBELM

WHY THEY DIDN’T GO AWAY

SOMEONE HIJACKED THE WHOLE

CONCEPT BECAUSE OF LIMITATIONS
IN MEASURING RED CELLS

(pssst…IT WAS THE CLASSIC IMPEDANCE PEOPLE)

CLASSIC IMPEDANCE
• MCHC – LOCKED INTO A NARROW, NORMAL
RANGE

• MCHC BECAME A QC / QA PARAMETER

RATHER THAN A CLINICAL PARAMETER

• LABS WERE ENCOURAGED TO USE THE

MCH INSTEAD

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 IT’S ALL ABOUT…..

• CLASSIC IMPEDANCE vs SHEATH FLOW

• NATURAL DEFORMABILITY OF RBC

• HYPERTONIC vs ISOTONIC DILUENT

• FIXED RBC AND NORMALIZED RESULTS

CLASSIC IMPEDANCE SHEATH FLOW IMPEDANCE

NATURAL DEFORMABILITY OF RED BLOOD CELLS

NORMAL CELLS DO THIS

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 BUT…WHEN THE RED CELLS ARE NOT NORMAL

HYPOCHROMIC CELLS ‘OVER DEFORM’ IN CLASSIC IMPEDANCE

SHEATH FLOW CONTROLS THIS

CELLS ZIP THROUGH TOO FAST CONTROLED BY SHEATH FLOW

SIZE IS UNDERESTIMATED ACCURATELY SIZED
HCT ARTIFICIALLY DECREASED ACCURATE HCT AND MCHC
MCHC ARTIFICIALLY INCREASED

WHEN THE RED CELLS ARE NOT NORMAL

HYPERCHROMIC CELLS DON’T DEFORM ENOUGH IN CLASSIC

IMPEDANCE
SHEATH FLOW CONTROLS THIS

CELLS MOVE THROUGH TOO SLOW CONTROLED BY SHEATH FLOW

SIZE IS OVER ESTIMATED ACCURATELY SIZED
HCT ARTIFICIALLY INCREASED ACCURATE HCT AND MCHC
MCHC ARTIFICIALLY DECREASED

THE RESULT IS
“Clamped” MCHC IN CLASSIC IMPEDANCE
Classic Conductance MCHC

High MCHC’s “normalized”

35.2
Clamped MCHC
Range

31.8
Low MCHC’s “normalized”

Reference MCHC Result

Reference: B.Bull, The Validity of the MCHC as Measured By Various Analyzers, presented at AACC, July 1992.

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 SO…WITH CLASSIC IMPEDANCE

IF YOUR MCHC GOES OVER

35.5 OR SO…SOMETHING IS WRONG
WITH YOUR INSTRUMENT, NOT THE
PATIENT

HOW HELPFUL IS THAT ?

Hydrodynamic Focusing - wider dynamic range

37.1
Hydrodynamic
MCHC

30.4

30.4 Reference MCHC 36.7

MCHC

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 REFERENCE RANGES AND
95 % CONFIDENCE LIMITS

IF THE REFERENCE RANGE

ENCOMPASSES 95 % OF THE NORMAL
PEOPLE….

…..WHERE ARE THE OTHER 5 %

MCHC

BUT WE HAVE SHEATH FLOW

SO WE’RE GOOD – RIGHT ?

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MAYBE NOT SO MUCH….

WHAT TO DO
• STOP THE RULES OF 3 – THEY DON’T
WORK IF THE RED CELLS ARE
ABNORMAL AND….

• WE HAVE THE RED CELL INDICES

• IF THE INDICIES ARE OUT OF WHACK,

INVESTIGATE

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 WHAT’S OK

• LOW MCV, LOW MCHC -THERE ARE

MICROCYTIC HYPOCHROMIC
ANEMIAS

• LOW MCV, NORMAL MCHC IS OK –

THERE ARE HEMOGLOBINOPATHIES

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 WHAT’S NOT OK
• MCHC > 37..AND WHAT CAN CAUSE IT

– RBC AGGLUTINATION
– LIPEMIA
– HEMOLYSIS
– LOW SODIUM
– ABNORMAL OSMOLALITY
(OFTEN CHEMOTHERAPY)

FASTEST WAY TO INVESTIGATE

AND I KNOW YOU DON’T WANT TO HEAR

THIS………

SPIN A HEMATOCRIT
• LIPEMIA
• HEMOLYSIS
• ABNORMAL SODIUM OR OSMOLALITY

…and if you can’t spin a HCT you could centrifuge the tube

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WHAT IF IT LOOKS LIKE THIS ?

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 HEAT IT

ABNORMAL SODIUM ? HOW DOES THAT WORK ?

HYPO OR HYPERNATREMIA
(low or high sodium for us non-chemists)

• HIGH NA
IN VIVO IN ISOTONIC DILUENT RESULT
HIGH HCT
HIGH MCV
H2O OUT H2O IN LOW MCHC

• LOW NA LOW HCT

LOW MCV

HIGH MCHC

H2O IN H2O OUT

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 • OK…SODIUM IS 132
• HOW DO I FIX IT?

• RECALCULATE INDICES WITH SPUN HCT

• DILUTE WITH INSTRUMENT DILUENT AND

LET EQUILIBRATE

• NORMAL NA
• NO LIPEMIA
• NO HEMOLYSIS

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 WHAT IT MIGHT BE AND WHAT TO DO

look at a slide

• HGB SS, C, OR SC DISEASE

– LET IT BE (UNLESS THE MCHC IS > 38)

or…
HEREDITARY SPHEROCYTOSIS

ONE MORE THING….DEHYDRATION CAN CAUSE A

HIGH MCHC

HIGH ALCOHOL LEVEL

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 WHAT’S NOT OK
• NORMAL OR HIGH MCV, LOW MCHC

– HIGH SODIUM
– AGED SAMPLE
– VERY HIGH GLUCOSE
– VERY HIGH WBC

NA 176

HIGH MCV / LOW MCHC……………………NOT LIKELY

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 HIGH MCV / LOW MCHC

• OTHER LAB RESULTS

– NA 144 SPUN HCT = 26%
– GLUCOSE 1494 RECALCULATE INDICES

OR DILUTE THE SAMPLE AND LET IT ‘EQUILIBRATE’

SAMPLE AGE
1 HOUR

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24 HOURS ROOM TEMPERATURE

48 HOURS ROOM TEMPERATURE

VERY HIGH WBC - LYMPHOCYTES

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 THE PROBLEM IS…..
- WBCs SHOW UP IN THE RBC
- WBCs ARE BIG
- WBCs HAVE NO HGB

LETTING GO OF THE RULES OF 3…..A FINAL LESSON

….

Light travels
faster than
sound. This
is why some
people appear
bright until
you hear
them speak

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AND ONE MORE THING…..

CALIBRATION DIFFERENCES

PERFECT HGB -0.2, HCT + 0.4 HGB +0.2, HCT - 0.4

HGB HCT MCHC HGB HCT MCHC HGB HCT MCHC

12.1 37 32.7 11.9 37.4 31.8 12.3 36.6 33.6

12.6 36.8 34.2 12.4 37.2 33.3 12.8 36.4 35.2

13.0 37 35.1 12.8 37.4 34.2 13.2 36.6 36.1

12.6 36.5 34.5 12.4 36.9 33.6 12.8 36.1 35.5

12.0 36.8 32.6 11.8 37.2 31.7 12.2 36.4 33.5

12.5 36.6 34.2 12.3 37 33.2 12.7 36.2 35.1

11.9 36.9 32.2 11.7 37.3 31.4 12.1 36.5 33.2

12.6 36.5 34.5 12.4 36.9 33.6 12.8 36.1 35.5

12.7 36.3 35.0 12.5 36.7 34.1 12.9 36.3 35.5

12.5 37 33.8 12.3 37.4 32.9 12.7 36.6 34.7

IF YOU CAN’T HIT THE TARGET…MAKE SURE YOUR ON

THE SAME SIDE.

PERFECT HGB - 0.2, HCT - 0.4

HGB HCT MCHC HGB HCT MCHC

12.1 37.0 32.7 11.9 36.6 32.5

12.6 36.8 34.2 12.4 36.4 34.1

13.0 37.0 35.1 12.8 36.6 35.0

12.6 36.5 34.5 12.4 36.1 34.3

12.0 36.8 32.6 11.8 36.4 32.4

12.5 36.6 34.2 12.3 36.2 34.0

11.9 36.9 32.2 11.7 36.5 32.1

12.6 36.5 34.5 12.4 36.1 34.3

12.7 36.3 35.0 12.5 36.3 34.4

12.5 37.0 33.8 12.3 36.6 33.6

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 THANK YOU

QUESTIONS ???

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