Esr

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ESR IS erythrocyte sedimentation rate. it is used as a prognostic marker. it is non specific test

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Esr

  1. 1. ERYTHROCYTE SEDIMENTATION RATE WITH SPECIAL REFERENCE TO ZSR & METHOD OF ESR IN INFANTS MODERATOR- Dr SANJEEV NARANG
  2. 2. ERYTHROCYTE SEDIMENTATION RATE DEFINITION The Length of fall of the top of the column of erythrocytes in a given interval of time is called ERYTHROCYTE SEDIMENTATION RATE
  3. 3. HISTORY <ul><li>THE ESR TEST WAS INVENTED IN 1897 BY POLISH DOCTOR EDMUND BIERNACKI . </li></ul><ul><li>IN 1918 SWEDISH PATHOLOGIST ROBERT SANNO FAHRAEUS DECLARED THE SAME & ALONG WITH ALF VILHELM WESTERGREN ARE EPONYMOUSLY REMEMBERED FOR FAHRAEUS-WESTERGREN TEST. </li></ul>
  4. 4. TERMS <ul><li>ACUTE PHASE REACTANT –A substance in the blood that increases as a response to an acute condition such as INFECTION,INJURY,BURNS etc. </li></ul><ul><li>ERYTHROCYTE SEDIMENTATION RATE (ESR) –The distance that RBC’s settle in a tube of blood in one hour. </li></ul><ul><li>ROULEAUX – The stacking of RBC’s ,caused by extra or abnormal proteins in the blood that decrease the normal distance red cells maintain between each other. </li></ul>
  5. 5. FACTORS INFLUENCING E.S.R <ul><li>FACTORS THAT INCREASE E.S.R </li></ul><ul><li>OLD AGE </li></ul><ul><li>FEMALE </li></ul><ul><li>PREGNANCY </li></ul><ul><li>ANEMIA </li></ul><ul><li>R.B.C ABNORMALITIES </li></ul><ul><li>MACROCYTOSIS </li></ul><ul><li>TECHNICAL FACTORS </li></ul><ul><li>DILUTION PROBLEMS </li></ul><ul><li>INCREASED TEMP. OF SPECIMEN </li></ul><ul><li>TILTED E.S.R TUBE </li></ul><ul><li>ELEVATED FIBRINOGEN LEVELS </li></ul><ul><li>INFECTION </li></ul><ul><li>INFLAMMATION </li></ul><ul><li>MALIGNANCY </li></ul><ul><li>FACTORS THAT DECREASES ESR </li></ul><ul><li>EXTREME LEUKOCYTOSIS </li></ul><ul><li>POLYCYTHEMIA </li></ul><ul><li>RBC ABNORMALITIES </li></ul><ul><li>SPHEROCYTOSIS </li></ul><ul><li>ACANTHOCYTOSIS </li></ul><ul><li>MICROCYTOSIS </li></ul><ul><li>TECHNICAL FACTORS </li></ul><ul><li>DILUTION PROBLEMS </li></ul><ul><li>INADEQUATE MIXING </li></ul><ul><li>CLOTTED BLOOD SAMPLE </li></ul><ul><li>SHORT ESR TUBE </li></ul><ul><li>VIBRATION DURING TESTING </li></ul><ul><li>PROTEIN ABNORMALITIES </li></ul><ul><li>HYPOFIBRINOGENEMIA </li></ul><ul><li>HYPOGAMMAGLOBULINEMIA </li></ul><ul><li>DYSPROTEINEMIA </li></ul>
  6. 6. STAGES OF ESR <ul><li>Initial 10 minutes –little sedimentation as Rouleaux formation –STAGE OF ROULEAUX </li></ul><ul><li>Next 40 minutes –settling occurs at constant rate –STAGE OF SEDIMENTATION </li></ul><ul><li>Final 10 minutes – sedimentation slows as cell pack at bottom of tube </li></ul>
  7. 7. WESTERGREN’S METHOD <ul><li>Reference method. </li></ul><ul><li>30 cm long 2.5 mm internal diameter. </li></ul><ul><li>Calibrated from 0 to 200. </li></ul><ul><li>Capacity 1 ml. </li></ul><ul><li>Rack is used with levelers as needed for vertical tube. </li></ul><ul><li>REAGENT – 0.105 M (0.10 – 0.156 ) of sodium citrate is used as a anticoagulant – diluent. </li></ul>
  8. 8. PROCEDURE-WESTERGREN <ul><li>Add 2 ml of whole blood to 0.5 ml of 3.8% sodium citrate & mix. </li></ul><ul><li>Fill pipette up to zero mark. </li></ul><ul><li>Place pipette exactly in vertical position at room temperature. </li></ul><ul><li>After 1 hour the distance from 0 mark to top of RBC column is recorded as ESR, </li></ul>
  9. 9. MODIFIED WESTERGREN’S <ul><li>EDTA Instead of citrate as anticoagulant. </li></ul><ul><li>2 ml of EDTA diluted with 0.5 ml of 3.8 % sodium citrate or 0.5 ml of 0.85 % sodium chloride. </li></ul><ul><li>Undiluted EDTA blood gives poor precision. </li></ul><ul><li>DILUTED BLOOD = ( UNDILUTED ESR *0.86 ) -12. </li></ul>
  10. 10. ESR –NORMAL VALUES (WESTERGREN’S ) <ul><li>AGE (YEARS) 95%UPPER LIMITS(MM IN HOUR) </li></ul><ul><li>MEN </li></ul><ul><li>17 – 50 10 </li></ul><ul><li>51 – 60 12 </li></ul><ul><li>61 – 70 14 </li></ul><ul><li>>70 ABOUT 30 </li></ul><ul><li>WOMEN </li></ul><ul><li>17 – 50 12 </li></ul><ul><li>51 – 60 19 </li></ul><ul><li>61 – 70 20 </li></ul><ul><li>>70 ABOUT 35 </li></ul><ul><li>PREGNANCY </li></ul><ul><li>First half 48 (62 if anemia) </li></ul><ul><li>Second half 70 (95 if anemia) </li></ul>
  11. 11. WINTROBE’S METHOD <ul><li>Wintrobe’s tube </li></ul><ul><li>Length = 110 mm. Internal Diameter 3.0 mm </li></ul><ul><li>Two markings . </li></ul><ul><li>1st marking for ESR (ABOVE DOWNWARDS ) </li></ul><ul><li>2 nd marking for PCV (BELOW UPWARDS ) </li></ul><ul><li>GRADUATION FROM 0 TO 100 </li></ul><ul><li>Wintrobe’s tube stand. </li></ul><ul><li>Pasteur pipette </li></ul><ul><li>Timer </li></ul>
  12. 12. PROCEDURE <ul><li>Mix blood carefully with EDTA anticoagulant. </li></ul><ul><li>Fill tube up to zero mark. </li></ul><ul><li>Place the tube exactly in vertical position in stand. </li></ul><ul><li>Set timer for one hour. </li></ul><ul><li>At the end of one hour note the level of erythrocyte column in mm after one hour. </li></ul>
  13. 13. WINTROBE’S METHOD
  14. 14. PRECAUTIONS <ul><li>Wash the tubes under running water using a thick wire. </li></ul><ul><li>Dry the tube in incubator. </li></ul><ul><li>In case of infants & if blood is insufficient use LANDAU METHOD. </li></ul>
  15. 15. NORMAL VALUES BY WINTROBE METHOD <ul><li>MALE = 0-9 MM AFTER 1 st HOUR </li></ul><ul><li>FEMALE = 0-20 MM AFTER 1 st HOUR </li></ul>
  16. 16. MICRO SEDIMENTATION METHOD (LANDAU ) <ul><li>REQUIREMENT. </li></ul><ul><li>FASTING CAPILLARY BLOOD (FINGER TIP , HEEL OR TOE ). </li></ul><ul><li>5.0 g / dl sodium citrate solution. </li></ul><ul><li>LANDAU PIPETTE (GRADUATED FROM 0 TO 50 MM ). </li></ul><ul><li>LANDAU Pipette stand. </li></ul><ul><li>Suction device for drawing blood into pipette. </li></ul><ul><li>Capillaries for blood collection. </li></ul>
  17. 17. PROCEDURE. <ul><li>Attach landau pipette to suction device. </li></ul><ul><li>Draw 5.0 g/dl sodium citrate up to 1st line of stem. </li></ul><ul><li>Draw blood by suction device up to 2 nd mark. </li></ul><ul><li>Draw citrate / blood into bulb & mix thoroughly. </li></ul><ul><li>Force back the mixture into stem of pipette. </li></ul><ul><li>Set the upper level to 0 mark at top. </li></ul><ul><li>Place it in vertical stand. </li></ul><ul><li>Note reading after one hour. </li></ul>
  18. 18. NORMAL VALUES <ul><li>MALE = 0-5 MM AFTER 1 st HOUR </li></ul><ul><li>FEMALE = 0-8 MM AFTER 1 st HOUR </li></ul>
  19. 19. CHILDREN <ul><li>NEWBORN 0 TO 2 MM/HR </li></ul><ul><li>NEONATAL TO PUBERTY 3 TO 13 MM/HR </li></ul><ul><li>8 DAYS AFTER DELIVERY ABOUT 4MM/HR </li></ul><ul><li>14 DAYS AFTER DELIVERY ABOUT17MM/HR </li></ul>
  20. 20. SOURCES OF ERROR <ul><li>Proper anticoagulant -1)right volume. </li></ul><ul><li>-2)rightconcentration. </li></ul><ul><li>Bubbles left in tube. </li></ul><ul><li>Hemolysis. </li></ul><ul><li>Un cleanliness of tube. </li></ul><ul><li>Tilting of tube. </li></ul><ul><li>Altered temperature. </li></ul><ul><li>Time after collection . </li></ul>
  21. 21. VES MATIC 20 INSTRUMENT <ul><li>AUTOMATED BENCH TOP ANALYSER TO MEASURE ESR. </li></ul><ul><li>BLOOD COLLECTED IN CUVETS. </li></ul><ul><li>SAMPLE IS LEFT TO SEDIMENT. </li></ul><ul><li>18 DEGREE SLANTING OF TUBES CAUSES ACCLERATION OF ESR. </li></ul><ul><li>RESULTS COMPAREABLE TO </li></ul><ul><li>1)WESTERGREN S 1 st HOUR TO BE OBTAINED IN 25 MINUTES. </li></ul><ul><li>2)WESTERGREN S 2 nd HOUR TO BE OBTAINED IN 45 MINUTES. </li></ul>
  22. 22. ZETA POTENTIAL <ul><li>THE ZETA POTENTIAL RESULTS FROM NEGATIVELY CHARGED SIALIC ACID GROUPS ON THE RED CELL MEMBRANE. </li></ul><ul><li>FIBRINOGEN & GAMMA GLOBULINS DECREASE ZETA POTENTIAL. </li></ul><ul><li>DECREASED ZETA POTENTIAL RESULTS IN INCREASED ROULEAUX FORMATION. </li></ul><ul><li>THIS RESULTS IN INCREASED ESR. </li></ul><ul><li>THIS MECHANISM IS MOST LIKELY EXPLANATION FOR INCREASED ESR IN DISEASE. </li></ul>
  23. 23. ZETA SEDIMENTATION RATIO <ul><li>DEFINITION - IT IS THE MEASUREMENT OF THE EASE WITH WHICH RBC’S WILL PACK UNDER A STANDARDISED COMPACTION – DISPERSION STRESS. </li></ul><ul><li>IT IS INVERSELY RELATED TO ZETA POTENTIAL OF THESE CELLS WHEN SUSPENDED IN PARTICULAR PLASMA UNDER CONSIDERATION. </li></ul>
  24. 24. ZETA SEDIMENTATION RATIO <ul><li>.REQUIRES A ZETAFUGE. </li></ul><ul><li>ZETAFUGE IS A CENTRIFUGE WHICH REQUIRES SPIN CAPILLARY TUBES IN VERTICAL POSITION IN FOUR 45 SECONDS CYCLES. </li></ul><ul><li>ROULEAUX FORMATION & SEDIMENTATION IN JUST 3 MINUTES. </li></ul><ul><li>READING IS KNOWN AS ZETACRIT. </li></ul><ul><li>ZETA SEDIMENTATION RATIO = TRUE Hct / ZETACRIT X 100. </li></ul><ul><li>NORMAL VALUES = 41 TO 54 % FOR BOTH SEXES. </li></ul>
  25. 25. PROCEDURE <ul><li>A BLOOD SAMPLE OF 100 ul CONTAINED IN A VERTICAL TUBE IS SPUN AT 400 rpm FOR 45 SECONDS. </li></ul><ul><li>THE RESULTANT 7-8 g FORCE CAUSES RBC’S TO TRAVEL OUTWARD UNTIL THEY APPROACH THE OUTER EDGE OF THE TUBE. </li></ul><ul><li>THE CAPILLARY TUBES ARE ROTATED 180 DEGREES & CENTRIFUGE IS RESTARTED. </li></ul><ul><li>AS CENTRIFUGE HEAD REGAINS IT’S OPERATING SPEED THE CLUMPED RBC’S NOW TRAVEL FROM INNER WALL OF TUBE . </li></ul><ul><li>THEY ARE PARTIALLY DISPERSED DURING THE INITIAL PHASES OF THIS JOURNEY BEFORE BEING DEPOSITED ONCE MORE IN OUTER WALL. </li></ul>
  26. 26. PROCEDURE <ul><li>IN THE PROCESS THEY ARE EXPOSED TO NORMAL DOWNWARD FORCE OF GRAVITY AND THUS COME TO REST UPON OUTER EDGE OF TUBE AT POINT SOMEWHAT LOWER THAN STARTING PHASE. </li></ul><ul><li>THIS PROCESS IS REPEATED 4 TIMES . </li></ul><ul><li>THIS CAUSES RBC’S TO FOLLOW ZIG ZAG PATH DOWN THE CAPILLARY TUBE & BECOMES MORE DENSELY PACKED. </li></ul><ul><li>FOUR 45 SEC. CYCLES OF COMPACTION ,DISPERSION & RECOMPACTION ARE EMPLOYED . </li></ul><ul><li>AT THE CONCLUSION OF THIS 3 MINUTE PERIOD,THE DEGREE OF COMPACTION ACHIEVED BY RBC’S ARE MEASURED. </li></ul>
  27. 27. MEASUREMENT OF ZSR <ul><li>TO MEASURE ZSR A CAPILLARY TUBE IS READ AFTER THE COMPACTION – DISPERSION CYCLES . </li></ul><ul><li>ZSR CORRESPONDS WITH UPPER MENISCUS OF THE RED CELL COLUMN . </li></ul><ul><li>THE MENISCUS OF ZETACRIT IS NOT COMPLETELY HORIZONTAL. </li></ul><ul><li>THE TAIL OF RED CELLS RISES ABOVE IT ON ONE SIDE & A SMALL WEDGE OF PLASMA DEPRESSES IT ON THE OTHER. </li></ul><ul><li>ZETACRIT IS MARKED AT YHE “ KNEE “ OF THE CURVE BETWEEN THE RED CELLS & THE MENISCUS . </li></ul>
  28. 28. ADVANTAGES OF ZSR <ul><li>CAPILLARY TUBES ARE EASIER TO FILL. </li></ul><ul><li>REQUIRES LESS SAMPLE. </li></ul><ul><li>CAPILLARY TUBES ARE CHEAPER THAN STANDARD ESR TUBES. </li></ul><ul><li>ZSR IS UNAFFECTED BY ANEMIA . </li></ul>
  29. 29. DRAWBACKS OF ZSR <ul><li>RESULTS ARE EXPRESSED IN NEW UNITS i.e. % RATHER THAN IN MM / HOUR. </li></ul><ul><li>NEED TO PURCHASE SPECIAL CAPILLARY TUBES & A SPECIFIC NEW INSTRUMENT CALLED ZETAFUGE . </li></ul>
  30. 30. APPLICATIONS OF ZSR <ul><li>1- IN THOSE SITUATIONS WHERE ESR IS ALREADY USED. </li></ul><ul><li>2-ANEMIC PATIENTS. </li></ul><ul><li>3-MULTIPHASIC HEALTH SCREENING CENTRES. </li></ul><ul><li>4-BLOOD BANK DONORS. </li></ul>
  31. 31. ZETAFUGE
  32. 32. DETERMINATION OF ZSR
  33. 33. VALUES OF ZSR <ul><li>NORMAL 51 TO 54 % </li></ul><ul><li>MILDLY ELEVATED 55 TO 59 % </li></ul><ul><li>MODERATELY ELEVATED 60 TO 64 % </li></ul><ul><li>MARKEDLY ELEVATED >65 % </li></ul>
  34. 34. CORRECTED ESR <ul><li>TO ELIMINATE THE INFLUENCE OF ANEMIA ON ESR. </li></ul><ul><li>CORRECTED ACCORDING TO VOLUME OF CELLS . </li></ul>
  35. 35. CORRECTION FOR ESR <ul><li>FIND THE HORIZONTAL LINE WHICH REPRESENT ESR FOR 1st hour. </li></ul><ul><li>FOLLOW THIS ACROSS CHART TILL IT INTERSECTS THE VERTICAL LINE. </li></ul><ul><li>VERTICAL LINE REPRESENTS BLOOD CELL VOLUME. </li></ul><ul><li>FOLLOW NEAREST CURVED LINE TILL IT INTERSECTS HEAVY LINE AT 1) 42 % PER 100 ml > FEMALE </li></ul><ul><li>2) 47 % PER 100 ml > MALE. </li></ul><ul><li>AT POINT OF INTERSECTION READ THE VALUE ON HORIZONTAL LINE FOR CORRECTED ESR. </li></ul>
  36. 36. GRAPH FOR CORRECTED ESR
  37. 37. CLINICAL SIGNIFICANCE OF ESR. <ul><li>TO FOLLOW THE COURSE OF DISEASE. </li></ul><ul><li>TO ESTABLISH PROGNOSIS IN CERTAIN CHRONIC DISEASES. </li></ul><ul><li>INCREASE IN TWO OR MORE CONSECUTIVE TESTS INDICATES CONTINUATION OF INCREASED ACTIVITY. </li></ul><ul><li>TO DISTINGUISH BETWEEN ORGANIC/NON ORGANIC DISORDERS. </li></ul><ul><li>TO SUPPORT THE DIAGNOSIS. </li></ul>
  38. 38. LIMITATIONS OF ESR <ul><li>ESR IS A NON SPECIFIC PHENOMENON & REFLECTS ONLY CHANGE IN PLASMA PROTEINS PATTERN & VARIATION IN RED CELL COUNT. </li></ul><ul><li>CANNOT BE USED AS A DIAGNOSTIC TOOL. </li></ul><ul><li>DOES NOT INDICATE THE NATURE OF DISEASE. </li></ul>
  39. 39. REFERENCES <ul><li>HENRY’S CLINICAL DIAGNOSIS &MANAGEMENT BY LAB. METHODS 21/e </li></ul><ul><li>DACIE & LEWIS PRACTICAL HEMATOLOGY 10 /e </li></ul><ul><li>T.B. OF MEDICAL LAB TECHNOLOGY-GODKAR 2/e </li></ul><ul><li>VARIOUS INTERNET SITES </li></ul>
  40. 40. THANKS <ul><li>BY- </li></ul><ul><li>Dr RAVI JAIN </li></ul>

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