Erythrocyte Sedimentation Rate (ESR), a lecture for medical lab technicians at Baquba Technical Institute, Middle Technical University. All theoretical and practical notes about the test.

1. Erythrocyte Sedimentation
Rate (ESR)
Hussein A. Abid 
Lecture: 04
Middle Technical University
Technical Institute of Baquba
Medical Laboratory Technology Department
Academic year 2019-2020 – Spring semester
Medical Laboratory Technology & Quality Control Applications
Module code: MLT113
L.No.: MLT113-20-T-04

2. Erythrocyte Sedimentation Rate (ESR)
• A nonspecific test for inflammatory and necrotic
conditions.
• May also be increased in situations of physiologic
stress, such as pregnancy.
• In these conditions, there is a change in blood
proteins which leads to a clumping of red blood cells.
• Measures the speed with which erythrocytes settle in
a tube of blood which has been mixed with an
anticoagulant.
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3. ESR
• Cells which have clumped due to inflammatory
and necrotic conditions settle more rapidly than
single cells.
• Expressed in mm/h.
• There is a direct relationship between the ESR
and the course of such diseases; as the disease
improves, such as due to drug therapy, the ESR
decreases.
• Also called sedimentation sate and sed rate
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4. ESR
• Easy to perform, widely available and inexpensive
• Widely used as screening test
• Also used as a monitoring tool for response to
treatment in conditions in which it is raised
(tuberculosis, autoimmune diseases ..etc.)
• ESR is not diagnostic of any particular disease, but
rather is an indication that a disease process is
ongoing and must be investigated.
• ESR is affected by three factors: erythrocytes, plasma
composition, and mechanical/technical factors
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5. Methods
1. Westergren method
2. Wintrobe's method
3. Disposable ESR tubes (VES-MATIC 20)
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6. Principle
• This test is based on the fact that inflammatory and
necrotic processes cause an alteration in blood
proteins, resulting in an aggregation of red cells,
which make them heavier and more likely to fall
rapidly when placed in a special vertical tube.
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7. Materials and consumables
1. Westergren tube and rack
2. Trisodium citrate (31.3 g/ 1000 ml D.W.)
3. Pipette and tips
4. Blood sample
5. Timer
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8. Procedure
Notes:
 Patient must fasting at least 4 hours before testing.
 The blood sample must be mixed with
anticoagulant trisodium citrate as (1 anticoagulant:
4 blood), e.g. 0.4 ml of sodium citrate should be
mixed with 1.6 ml of blood.
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9. Procedure
1. Mix the diluted blood for at least 2 minutes on a rotator.
(The blood should be at room temperature). Check the
tube for clots using two applicator sticks.
2. Make certain the Westergren ESR rack is exactly level.
3. Fill the Westergren tube to exactly the 0 mark. Making
certain there are no air bubbles in the blood.
4. Place the tube in the rack. Be certain the tube fits
snugly and evenly into the grooves provided.
5. Allow the tube to stand for exactly 60 minutes.
6. At the end of 60 minutes records the number of
millimeters the red blood cells have fallen. This result is
the erythrocyte sedimentation rate in millimeters/hour.
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10. 09
Normal ranges of ESR
After 1 hour
Adult male < 15 mm/h
Adult female < 20 mm/h
Children < 13 mm/h
Or
𝑬𝑺𝑹(𝒎𝒎/𝒉) =
𝑨𝒈𝒆 𝒚𝒆𝒂𝒓𝒔
𝟐
+ 𝟓 (𝒇𝒐𝒓 𝒇𝒆𝒎𝒂𝒍𝒆𝒔 𝒐𝒏𝒍𝒚)
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11. Increased ESR
• Multiple myeloma
• Connective tissue disorders (rheumatoid arthritis,
systemic lupus erythematosus and other autoimmune
diseases)
• Tuberculosis
• Malignancies
• Severe anemia
• Menstruation
N.B.: in many cases it could be higher than 100 mm/h.
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12. Decreased ESR
• Polycythemia
• Severe Leukocytosis
• Sickle cell disease (anemia)
• Hereditary spherocytosis
• Congestive Cardiac Failure
• Corticosteroid use
• Hypofibrinogenemia
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13. Factors affecting ESR
A) Effect of plasma protein:
Increased in the concentration of fibrinogen and Immunoglobulins due
to tissue injury will increase rouleaux formation and hence the rate of
sedimentation. Plasma albumin retards sedimentation of RBCs.
B) The RBC size and number:
The size and number of RBCs that show alterations in their biconcavity,
like spherocytes and sickle cells, usually do not exhibit increase rate,
unless there is severe anemia. Increase red cell mass will retard the
sedimentation rate e.g. polycythemia.
C) Technical factors:
1) Perpendicularity of sedimentation tube, slight deviations from the
absolute. Vertical can increase the result. 2) Temperature (RT 18-25 °C)
higher temperature cause false high results due to reduction in plasma
viscosity (direct sun light). 3) Vibration can reduce the ESR.
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14. NOTES
 If the concentration of EDTA is greater than recommended, the ESR will be falsely
low.
 The anticoagulants sodium or potassium oxalate and heparin cause the RBCs to
shrink and the ESR will be falsely high.
 If the ESR stands for more than 60 minutes, the results will be falsely elevated. If
the test is timed for less than 60 minutes, invalidly low values are obtained.
 A marked increase (or decrease) in room temperature leads to increased (or
decreased) ESR result.
 Tilting of the ESR tube increases the ESR.
 Bubbles in blood cause invalid results.
 Fibrin clots present in the blood invalidate the test results.
 The ESR should be set up within 2 hours of blood collection. If EDTA is used as
the anticoagulant, the test may be set up within 6 hours if the blood has been
refrigerated.
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15. NOTES
 The ESR may be increased during menstruation, after the 12th week of
pregnancy, and postpartum.
 The ESR may be decreased in the presence of elevated white blood cell count,
albumin, and lipids.
 Drugs which may increase the ESR: dextran, heparin, oral contraceptives.
 Drugs which may decrease the ESR: albumin, aspirin, corticotropin, cortisone,
lecithin, steroids.
 In polymyalgia rheumatica, the ESR is monitored frequently to guide the
healthcare provider in determining dosage of prednisone needed for control of
symptoms.
 The ESR is usually very high (>55 mm/h) in patients with temporal arteritis. It is
essential that steroids be initiated immediately to avoid complications such as
blindness or stroke.
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