Standards of Care Lab Hematology. Dr. Imran Mirza Chief, Pathology & Laboratory Medicine Institute

Standards of Care Lab Hematology Dr. Imran Mirza Chief, Pathology & Laboratory Medicine Institute OBJECTIVES • To elaborate on “Standard of Practice...
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Standards of Care Lab Hematology Dr. Imran Mirza Chief, Pathology & Laboratory Medicine Institute

OBJECTIVES • To elaborate on “Standard of Practice/Care” • To identify practices in Lab Hematology that improve patient care • To discuss potential pitfalls that may lead to inappropriate diagnoses and treatment

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Standard Definition

A standard of care specifies appropriate treatment (CARE) based on scientific evidence and collaboration between medical professionals involved in the treatment of a given condition. http://en.wikipedia.org/wiki/Standard_of_care

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Standard Definition

An authoritative “document” setting forth criteria for performance and characteristics. A desired and achievable level of performance against which actual performance can be compared (benchmark). CLSI document ILA18A2.

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http://icsh.org/

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http://icsh.org/published-standards/

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http://www.bcshguidelines.com/index.html

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http://www.bcshguidelines.com/4_HAEMATOLOGY_GUIDELINES.html

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http://clsi.org/standards/

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Cases with Error

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Case 1 – CBC of a 35-year-old woman Difficult Draw – EDTA tube half-filled WBC

RBC HGB Hematocrit MCV RDW Platelets

Result 7.1

4.6 135  33.1  72 16.2 302

Reference Range 4.0 – 10.7 x 109/L

4.0 – 5.5 x 1012/L 118 – 160 g/L 36.1 – 44.3 % 80 – 100 fL 11.1 – 14.3% 150 – 400 x 109/L

• MCV spuriously low due to shrinkage of cells • Hematocrit low as it is calculated from MCV and RBC count 14

Case 2 – CBC of a 45-year-old man Improper Mixing of Blood in EDTA tube WBC

Result  2.8

Reference Range 4.0 – 10.7 x 109/L

RBC HGB Hematocrit MCV RDW Platelets

2.9  87 29 88 12.9  78

4.0 – 5.5 x 1012/L 118 – 160 g/L 36.1 – 44.3 % 80 – 100 fL 11.1 – 14.3% 150 – 400 x 109/L

• Pancytopenia • Cellular elements sequestered in the large clot in the tube 15

Case 3 –22-year-old man with diarrhea Intravenous Fluids in the ED WBC

Result  2.8

Reference Range 4.0 – 10.7 x 109/L

RBC HGB Hematocrit MCV RDW Platelets

3.2  89 29 87 12.9  121

4.0 – 5.5 x 1012/L 118 – 160 g/L 36.1 – 44.3 % 80 – 100 fL 11.1 – 14.3% 150 – 400 x 109/L

• Pancytopenia • Blood drawn from the same arm with IV line and distally 16

Standards of Care Lab Hematology • For CBC o Collect venous blood into an EDTA (lavender) tube o Fill the tube completely o Mix the blood well after collection o Transport to the laboratory timely • If patient is receiving intravenous fluids o Draw venous blood from the opposite arm o In case of the same arm, draw blood from a site distal to the IV line insertion site 17

Case 4 –25-year-old woman with fever Schistocytes 2+ WBC

Result  19.7

Reference Range 4.0 – 10.7 x 109/L

RBC HGB Hematocrit MCV RDW Platelets

4.6 129 42.9 82 15.2  81

4.0 – 5.5 x 1012/L 118 – 160 g/L 36.1 – 44.3 % 80 – 100 fL 11.1 – 14.3% 150 – 400 x 109/L

• False diagnosis of Thrombotic Thrombocytopenic purpura • ADAMTS13 test - normal 18

Case 4 –25-year-old woman with fever Schistocytes

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Case 5 –59-year-old woman with treated myeloma

Artifactual Rouleaux Formation WBC

RBC HGB Hematocrit MCV RDW Platelets

Result Reference Range 5.1 4.0 – 10.7 x 109/L

3.9 102 42.9 95 15.4 159

4.0 – 5.5 x 1012/L 118 – 160 g/L 36.1 – 44.3 % 80 – 100 fL 11.1 – 14.3% 150 – 400 x 109/L

• Poorly made smear with thick leading edge • SPEP and UPEP with IFE and bone marrow exam – negative 20

Standards of Care Lab Hematology • Specific red cell morphologies should be reported as present using strict and specific criteria, e.g.: o schistocytes should have sharp edges and angles with no central pallor • Ability to interpret a smear depends on its quality

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Case 6 –22-year-old woman with Sickle Trait Iron Deficiency vs. Hemoglobinopathy WBC

Result 6.1

Reference Range 4.0 – 10.7 x 109/L

RBC HGB Hematocrit MCV RDW Platelets

4.5  98  34  72  15.5  449

4.0 – 5.5 x 1012/L 118 – 160 g/L 36.1 – 44.3 % 80 – 100 fL 11.1 – 14.3% 150 – 400 x 109/L

Ferritin CRP

42 ng/mL 14.7 mg/L

20-300 ng/mL 2% immature granulocytes. • Look for characteristics that are unusual for reactive neutrophilic leukocytosis before establishing this diagnosis. • There should be a low threshold for ordering a PCR test for BCR/ABL1 on peripheral blood in a patient with neutrophilic leukocytosis. 27

Case 8 – 24-year-old woman with Hx of Neuroblastoma treatment and bruising

Diagnosis: Relapse vs Secondary MDS WBC

HGB Platelets Immature Platelet Fraction (IPF)

Result 5.6

14.1  17 23.9%

Reference Range 4.0 – 10.7 x 109/L

118 – 160 g/L 150 – 400 x 109/L 0.9% - 7%

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Case 8 – 24-year-old woman with Hx of Neuroblastoma treatment and bruising

Diagnosis: ITP (immature platelet fraction >7%)

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Standards of Care Lab Hematology • Any new findings of thrombocytopenia should be evaluated by review of the peripheral blood smear. • Platelet indices, including MPV and the IPF, should be used in conjunction with the platelet count to help determine whether thrombocytopenia is related to production defects or peripheral destruction.

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References •

Glassy EF, ed. Color Atlas of Hematology: An illustrated Field Guide Based on Proficiency Testing. Northfield, IL. CAP Press: 1998.



Swedlow SH, Campo E, Harris NL, et al. eds. WHO Classification of Tumous of Hematopoietic and Lymphoid Tissue. Lyon. France: IARC; 2008.



Kjeldsberg CR, ed. Pactical Diagnosis of Hematologic Disorders, Benign Disorders. 4th ed. ASCP Press; 2006.

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Take Home Messages • ICSH, BCSH, and CLSI are some of the main organizations that can be referred to for Standards of Care in Lab Hematology

• “Above all, do no harm.”

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