Immature Granulocytes (IG% & IG#) - · PDF file2 LIS Immature Granulocytes (IG% & IG#) RDW-SD...

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1 Selke Mantie, MLS (ASCP), CLS (CSMLS), SSGBC Describe new parameter immature granulocyte (IG) and it’s impact on patient care. Understand how new technology can impact “SCAN/MDIFF” workflow. Explore new pathways to improve six part auto-differential reporting. Understand defining new criteria as it relates to value added information to improve patient care. Banner Goldfield (2013) Banner Casa Grande (2014) Banner University Medical Center (2015) – Phoenix, Tucson – North/South

Transcript of Immature Granulocytes (IG% & IG#) - · PDF file2 LIS Immature Granulocytes (IG% & IG#) RDW-SD...

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Selke Mantie, MLS (ASCP), CLS (CSMLS), SSGBC

Describe new parameter immature granulocyte (IG) and it’s impact on patient care.

Understand how new technology can impact “SCAN/MDIFF” workflow.

Explore new pathways to improve six part auto-differential reporting.

Understand defining new criteria as it relates to value added information to improve patient care.

Banner Goldfield (2013)Banner Casa Grande (2014)

Banner University Medical Center (2015) – Phoenix, Tucson –

North/South

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LIS

Immature Granulocytes (IG% & IG#) RDW-SD Automated nRBC’s Immature Platelet Fraction (IPF) Immature Retic Fraction (IRF) Reticulocyte Hemoglobin (RET-He)

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IPF (Immature Plt Fraction)% Immature PLT/Total PLT

Plts + IPF = Production disorder

Plts + IPF = Destruction mechanism or BM Recovery

Reflex to IPF when PLTC < 100,000Test Code: PLTC with IPF

Briggs, Carol et al. Assessment of an immature platelet fraction (IPF) in peripheral thrombocytopenia. British Journal of Haematology, 126, 93-99; 2003.

Marked Thrombocytopenia

IPF cut off 7.1

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Docs: Helps identify if it’s a “consumption” vs “production” cause of thrombocytopeniaPredict platelet count recovery over timeDetermine need for platelet transfusion

Oncologist: Using to triage patients as IPF recovers ~3 days earlier than PLTC

Pathologists:

Determine need for platelet transfusionDetermine if bone marrow study is needed due to thrombocytopenia

Pharmacy:Uses to determine if thrombocytopenia is due to HIT.

• Qualitative measure of Hgb in reticulocytes.• Cellular evaluation of iron status• Help diagnose iron deficiency (ID)• Monitor response to iron treatment• Decrease RBC transfusions by treating iron

deficiency in preoperative setting• Improve patient care and decreased re-

admission rate in ER Ortho patients.

40 year old woman presents to the ED with an episode of syncope the previous night with loss of consciousness for 1 minute.

History of menorrhagia. History of iron deficiency anemia treated with blood

transfusions, 2010.

Temp 36.8 HR 70 BP 106/60 RR 18 Sat 98% on room air

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Anemia Trick:MCV/RBC <13 favors thalassemia >13 favors iron

deficiency

The RET-He threshold for defining iron deficiency in adults is less than 29 pg(KDOQI Guidelines)

Care Sets1. Iron Profile 2. Anemia 3. Iron/EPO4. Pre-operative work up for elective surgery5. Orthopedic ER

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MonocyteBasophil Eosinophil Neutrophil Lymphocyte

MonocyteBasophil Eosinophil Neutrophil LymphocyteIG

Previous Analyzer5 Part Diff

Current Analyzer

6 Part Diff

•Identifies & QuantifiesImmature Myeloid cells

Immature Granulocyte (IG) PromyelocytesMyelocytesMetamyelocytes

Neutrophil count BandsNeutrophils

Immature Granulocytes - IG

DC Detection RF Detection

Measurement ofcell volume

Measurement of internal density

Nucleic acidGranules

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IMI ChannelDIFF Channel

Diff Channel: Quantifies nucleic acid & defines cell complexity.

RF measure cell densityDC measure cell size

More precise than 100-cell diff (Fernandes). Good correlation with flow (Fernandes). Better sensitivity and specificity than WBC alone in

predicting infection in patients admitted through the ED with suspected bacteremia (Ansari-Lari).

92% PPV in patients with positive blood cultures and IG >3% (Ansari-Lari).

IG can elevate in infection/inflammation even when the WBC and other markers are not elevated (Briggs).

IG, a direct cellular measure of leukopoiesis, may aid the ability to detect infection if added to current protocols

IG% and IG# –Early screen for sepsis

•Better indicator for infection than WBC•Comparable to ANC•IG% >1% indicates a left shift•IG% >3% may predict positive blood cultures with:

•98% specificity•92% PPV

–Detect myeloproliferative disorders–Infection – identification upon admission–Replace I/T Ratio and Bands

Neutrophil count includes bands

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Validate 220 samples which included the IG, IPF, IRF, RET-He, NRBC (automated), RDW-SD and MPV

Perform 200 cell manual differential on each sample by two different techs

Validate Cellavision DM96 with 200 cell differential on all 220 samples

Identify IG% cut off value for SCAN reflex

SCAN Trigger for IG% set at 5%

Laboratory Memo Interpretative messages SBAR Lab Facts Flyers/Memo’s In-services Clinical Rounds Support during week of “go live”. Facilitate Med. Exec. Committee’ meetings as

requested and or different physician groups

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Reporting CBC with 6 Part Diff !!

6 Part Diff 5 Part Diff

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25-year-old female with autoimmune disorder Admitted to hospital with severe hemolytic

anemia Treated with steroids but no improvement Elevated WBC:

Mild cough No signs and symptoms of infection Chest x-ray negative. No fevers or chills. WBC was coming down on discharge Clinical impression: Leukocytosis due to steroids

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Infection or Inflammation?

Reporting AUTO Diffs, can make trends more apparent for physicians.

Ansari-Lari, et al Am J of Clin Path 2003:120:795-799

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ITR = I:T Ratio = Immature neutrophils (bands, metamyelocytes, myelocytes, and promyelocytes) to Total Ratio (Manual Differential)

ITR has been used as an index to predict neonatal sepsis Controversial Generally accepted reference range < 0.2 Another study 0.05 – 0.27

Cut offs

Band count >10 (One possible criteria for SIRS)IT Ratio <0.2 has high negative predictive valueIG: >1% indicates a left shift>3% may predict positive blood cultures

Band Count is poorly reproducibleCriteria for Bands is subjective

Three different definitions“How pinched is the nucleus?”

If TRUTH = 10 Bands per 100 WBC (10% Bands)100 cell count 5% to 16% Bands

1,000 cell count 8% to 12% Bands

The manual band count is imprecise

ADIFF includes SEGS + BANDS

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If TRUTH = 10% Bands100 cell count can vary from 5% to 16% Bands

The manual band count is imprecise

What about the band?

Our sepsis trigger for bands is >10% !!

ITR & Manual ANC – double dip

in the “manual band count”

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Legend:

True Positive: results from both the instrument and the manual differential are positive (abnormal)

True Negative: results from both the instrument and the manual differential are negative (normal)

False Positive: results from the instrument are positive, but the manual differential is negative.

False Negative: results from the instrument are negative, but the manual differential is positive.

35.3

51.9

0 12.8

TN

TP

FN

FP

133 babies35% of acceptable ADIFF – forced to

MDIFF.Why?

S B A R

Situation Ig reported with ADIFF only IG not reported with MDIFF’sMandatory MDIFF in babies < 1 year

Path Reviews

Background Scan and MDIFF criteria defined for old technology. Path review criteria

Assessment Manual diffs are subjective, imprecise and labor intensive6 Part Automated Diffs with IG’s are objective, precise with no extra workPBS SCAN still required for instrument generated flagsDid current path reviews add value to patient care?

Recommendation Virtual View away CBCM from CPOEDoctors call pathology to request CBCMPatients < 1 year old – Perform PBS with coded comment on bands < 10 present.‐ If no abnormal cells seen – report ADIFF‐ If abnormal cells/blasts seen, perform MDIFFRe-define path reviews criteria to identify the truly abnormal cases.

LAB: Increase reporting CBC w/Auto DIFF. (IG) by 30% Remove mandatory MDIFF in kids < 1 yr. Re-define “left shift” Streamline path review criteria

Hospital Review Lab Care-sets with CCG. Computer alerts for sepsis to include IG’s Replace or modify ITR for babies

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Banner AZ RegionCriteria Requiring a Manual Diff ( 5 Part Diff)

Analyzer could not perform ADIFF

:::::

Age < 1 year old

WBC counts WBC counts <1,000 first timeIf the WBC cell line has a 50% or greater change, then a manual differential must be performed.

Significant abnormality (morphology)

Bands >15%META >1%MYELO ANYPRO ANYBLASTS ANYnRBC’s >1Abnormal (atypical lymphs) ANYReactive lymphs >5%Plasma Cells >1%

Smudge cells Smudge cells >10% of all cells present. Prepare albumin slide and perform MDIFF

Path Review If “path review” is ordered, perform a MDIFF

New rule added with New Analyzer (6 –Part Diff)

WBC > 25 & IG% > 5.0

Two sites: BBMC & BEMC Technologist – created a working worksheet with changes for

MDIFF and CBC Path Review. Created the 40 – 20 – 5 percent rule Updated WAM rules to allow CBC w/ ADIFF on kids < 1 year old Reviewed current RBC Morphology reporting. Removed the following from RBC Morphology:

BLISTER CABOT RINGS GIANT PLAT HGB C CRYST PYKN WBC SIDEROCYTES

Reporting format in LISRule

40 – 20 -10

No path.

40-20-10

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Sysmex% AUTO Diff   

Cellavision# of Cells

Acceptable Range Example

%Neut#Segs +#Bands

+/- 40 cells

IF Sysmex Neut% within + or – 40 of Cellavision Segs+Bands, THEN the AUTO Diff can be accepted.

Sysmex Neut% = 65%Cellavision:  Segs+Bands from 25%to 105% is acceptable.

%Lymph

%Mono

%Auto NRBCs

#Lymph (includesReactive and Plasmacytoidlymphs)

#Mono

#NRBC

+/- 20 cells

IF Sysmex Lymph% or Mono% within + or – 20 the number of cells seen on Cellavision, THEN the AUTO Diff can be accepted.

IF Sysmex Automated NRBC% within + or – 20 the number of NRBCs seen on Cellavision, THEN the AUTO Diff can be accepted.

Sysmex Lymph% = 30%Cellavision:  Lymphs from 10% to 50% is acceptable.

%IG

%Eos

%Basos

#Metas +#Myelos +#Pros

#Eos

#Basos

+/- 10 cells

IF Sysmex IG%, Eos% or Baso% within + or – 5 the number of cells seen on Cellavision, THEN the AUTO Diff can be accepted.

Sysmex IG% = 6%Cellavision:  Metas+Myelos+Prosfrom 1% to 11% is acceptable.

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Can Accept AUTO Diff!

Diff Count % Rule +/- Cells Cellavision # or Scope Acceptible

Neut 74.1 30 93 (Bands + Segs) Yes

Lymph 7.2 20 3 Yes

Monos 4.1 20 4 Yes

NRBC 0.0 20 0 Yes

EOS 0.0 10 0 Yes

Baso 0.6 10 1 Yes

Others (IG) 14.0 10 8 (Metas+Myelos+Pros) Yes

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IDA: RBC morphology changes suggestive of Iron Deficiency Anemia. Check Ret-He if not already performed (Order as RETIC-comprehensive).

NSAP: Nonspecific RBC morphology changes present. Review RBC indices.

What changes should be made to

the CBC reporting?

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IG

< 1 yr.

Change 50% Bands >15%

Banner AZ RegionCriteria Requiring a Manual Diff ( 6 Part Diff) After Pilot Study

Analyzer could not perform ADIFF

------

Age< 1 year old. *

WBC counts WBC counts <1,000 first timeIf the WBC cell line has a 50% or greater change, then a manual differential must be performed.

Significant abnormality (morphology)

Bands >15%META >1%MYELO ANYPRO ANY

BLASTS ANYnRBC’s >1Abnormal (atypical lymphs) ANYReactive lymphs >5%Plasma Cells >1%

Abnormal cells suspicious of malignancy ANY

Smudge cells Smudge cells >10% of all cells present. Prepare albumin slide and perform MDIFF

Path Review If “path review” is ordered, perform a MDIFFNew rule added with New Analyzer (6 –Part Diff)

WBC > 25 & IG% > 5.0

Quantity Cells on SCAN do not correlate with ADIFF (40 – 20 – 5 Rule)

*Scan – Report with ADIFF:“Less than 10% bands seen on PBS smear”

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PATH Review Old Procedure PilotProcedure

Change

PATH Review required

27% 3% Decreased Path Reviews 16%

PATH Review NOT required

73% 97%

PATH Review Old Procedure PilotProcedure

Change

PATH Review required

20% 2% Decreased Path Reviews 18%

PATH Review NOT required

80% 98%

BBMC

BEMC

Message Meaning Judgment/Formula WBC Abn. Scattergram WBC abnormal

scattergram Clustering in the WBC/Baso channel & DIFF Scattergram.

Lymphocytosis High lymphocyte count LYMPH#: > 10.0 x 103/uL Monocytosis High monocyte count MONO# : > 3.0 x103/uL

(< 18 yrs old) MONO#: >2.0 x103/uL (> 18 yrs old)

Eosinophilia High eosinophil count EO#: > 2.0 x 103/uL Basophilia High basophil count BA#: > 0.50 x 103/uL IG Present High immature

granulocytes IG%: > 5.0

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LDC= Leukocyte Differential Count

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Side by side comparison of criteria used on Previous Analyzer (5-Part Diff) to updated criteria for New Analyzer (6-Part Diff)

Scan of PBS slide confirms presence of Metas, Myelos and Pros, confirming IGs (Immature Granulocytes) identified by the Auto Diff. IG set at 5% for SCAN.

Reporting CBC w/ADIFF on babies with the following comment: “Less than 10% bands seen on peripheral blood smear”.

Leveraging the 6-Part Diff Increased Automated Diffs by 36% Decreased Pathology Reviews by 18%.

Manroe BL. The neonatal blood count in health and disease. Reference values for neutrophilic cells. J PEDIATR 1979;95:89-98.

Schelonka, R MC, USAF. Peripheral leukocyte leukocyte indexes in term infants count and healthy newborn, J PEDIATR 1994;125:603-6

P. Joanne Cornbleet, MD, PhD. Clinical Utility of the Band Count: Interpretation of the Peripheral Blood Film. Clinics in Laboratory Medicine; Vol 22; Number 1; March 2002; Department of Pathology, Stanford University Medical Center, Stanford, California

Barnes PW, et al. The international consensus group for hematology review: suggested criteria for action following automated CBC and WBC differential analysis. Barnes-Jewish Hospital, St. Louis, Missouri, USA. Lab Hematol.2005;11(2):83-90.

Kay L. Lantis, MT(ASCP) SH et al. Elimination of Instrument-Driven Reflex Manual Differential Leukocyte Counts: Optimization of Manual Blood Smear Review Criteria In a High-Volume Automated Hematology Laboratory; University of Michigan. Am J Clin Pathol 2003;119:656-662

Nigro K.G,Performance of an Automated Immature Granulocyte Count as a Predictor of Neonatal Sepsis Am J Clin Pathol2005;123:618-624

Engle, WD Circulating Neutrophils in Septic Preterm Neonates: Comparison of Two Reference Ranges. Pediatrics 1997;99;e10

Kuppermann, N. Immature Neutrophils in the Blood Smears of Young Febrile Children. Arch Pediatr Adolesc Med. 1999; 153:261-266.

Newman, TB. Interpreting Complete Blood Counts Soon After Birth in Newborns at Risk forSepsis. Pediatrics 2010;126;903; originally published online October 25, 2010;

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Gene L. Gulati, PhD, et al. Automated Lymphocyte Counts vs Manual Lymphocyte Counts in Chronic Lymphocytic Leukemia Patients. LABMEDICINE , Volume 42 Number 9, September 2011

Immature granulocyte measurement using the Sysmex XE-2100. Am J of Clin Path; 2003;120(5):795 –799.

Automated Enumeration of Immature Granulocytes. Am J Clin Pathol 2007; 128; 454-463