Immature Granulocytes (IG% & IG#) - · PDF file2 LIS Immature Granulocytes (IG% & IG#) RDW-SD...
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%.
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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.
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Gene Gulati, Ph.D et al. Purpose and Criteria for Blood Smear Scan, Blood Smear Examination and Blood Smear Review; Jefferson Medical College and Thomas Jefferson University Hospital. Ann Lab Med 2013;33:1-7
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