Haematology

The Department provides a comprehensive, UKAS accredited (ISO 15189) Haematology service for the University Hospitals of North Midlands, surrounding GPs and peripheral hospitals.

The Haematology Department forms part of the Blood Sciences Department at the University Hospitals of North Midlands. The Department is split over two sites: at the Royal Stoke University Hospital (RSUH) and County Hospital, Stafford.

At RSUH, the Pathology department can be found on the 2nd floor (via Lift A) of the Main building.

The County Hospital Blood Sciences department is located on the 1st floor of the Hospital (follow the signs to Specimen Reception).

The RSUH laboratory is open 24 hours a day, seven days a week, including Bank Holidays. This laboratory provides a wide repertoire of routine and specialist haematology tests and operates 24 hours a day. The vast majority of GP samples from Mid and North Staffordshire are analysed at this site. Outside core hours, services are limited to urgent work only.

The County laboratory is open to receive samples between 06:30 and 23:15, seven days per week, including Bank Holidays. It provides a limited repertoire of essential tests for ward and outpatient activity on the County site. Samples not received in the laboratory by 23:15 are transported to the RSUH Laboratory for analysis, or can be processed using the on-site point of care facilities. All queries regarding County patients outside of the laboratory opening hours should be directed to the RSUH laboratory.

The Clinical Haematology team are again a single department split over the two sites. Clinical advice is available 24 hours per day for both sites

The Haematology Department also encompasses the following sub-departments:

These ranges are age and sex related. Please note that uncertainty of measurement data (UOM) is available on request.

Haemoglobin reference range - premature neonates (g/L)

Gestational age - weeks

Low

High

24-25

179

209

26-27

165

215

28-29

175

211

30-31

169

213

32-33

165

205

34-45

175

217

36-37

177

209

Haemoglobin reference range - Male (g/L)

Age

Low

High

0-7 days

145

220

7-14 days

140

220

14 days to 1 month

125

200

1 -6 months

110

180

6 months - 2 years

100

135

2 - 6 years

105

135

6 - 12 years

110

140

12 - 18 years

115

155

18-65 years

130

160

> 65 years

130

180

Haemoglobin reference range - Female (g/L)

Age

Low

High

0-7 days

145

220

7-14 days

149

220

14 days to 1 month

125

200

1 -6 months

110

180

6 months - 2 years

100

135

2 - 6 years

105

135

6 - 12 years

110

140

12 - 18 years

115

155

18-50 years

120

160

50 - 65 years

115

165

>65 years

115

163

Haematocrit reference range – Male (L/L)

Age

Low

High

0 - 7 days

0.46

0.60

7 - 14 days

0.42

0.64

14 days - 1 month

0.39

0.63

1 - 2 months

0.35

0.55

2 months - 2 years

0.30

0.42

2 - 6 years

0.30

0.42

6 - 12 years

0.33

0.42

12 - 18 years

0.35

0.49

>18 years

0.37

0.51

Haematocrit reference range – Female (L/L)

Age

Low

High

0-7 days

0.46

0.60

7-14 days

0.42

0.64

14 days to 1 month

0.39

0.63

1 - 2 months

0.35

0.55

2 months - 2 years

0.30

0.42

2 - 6 years

0.30

0.42

6 - 12 years

0.33

0.42

12 - 18 years

0.35

0.45

18 - 50 years

0.36

0.46

50 - 65 years

0.37

0.48

>65 years

0.37

0.47

Mean Cell Volume reference range (fL)

Male

Female

Age

Low

High

Low

High

0 - 7 days

95

125

95

125

7 - 14 days

95

120

90

120

14 days - 1 month

86

120

86

120

1 - 2 months

85

120

85

120

2 - 3 months

80

115

80

115

3 months - 2 years

75

105

75

105

2 - 6 years

70

86

70

86

6 - 12 years

73

85

73

85

12 - 18 years

77

95

77

95

>18 years

78

98

78

100

RBC reference range (x10^12/L)

Male

Female

Age

Low

High

Low

High

0 - 7 days

3.90

5.50

3.90

5.50

7 - 14 days

3.90

5.50

3.90

6.30

14 days - 1 month

3.60

6.20

3.60

6.20

1 - 2 months

3.00

5.40

3.00

5.40

2 - 3 months

2.70

4.90

2.70

4.90

3 months - 2 years

3.10

4.50

3.10

4.50

2 - 6 years

3.70

5.30

3.70

5.30

6 - 12 years

3.90

5.30

3.90

5.30

12 - 18 years

4.00

5.20

4.00

5.20

18 - 65 years

4.50

5.30

4.10

5.10

>65 years

4.30

5.70

3.80

5.50

MCH reference range - Male and Female (pg)

Age

Low

High

0-14 days

31.0

37.0

14 days to 2 months

28.0

40.0

2 - 3 months

26.0

34.0

3  months - 2 years

25.0

35.0

2 - 6 years

23.0

31.0

6 - 12 years

24.0

30.0

12 - 18 years

25.0

33.0

18 years onwards

26.5

31.5

% Hypo RBC reference range

Age

Male

Female

All ages

≤5%

≤5%

Platelets reference range (x10^9/L)

Age

Male

Female

All ages

150-450

150-450

WBC Reference Range - Male and Female (x10^9/L)

Age

Low

High

0 - 14 days

10.0

26.0

14 days - 2 months

6.0

21.0

2 - 6 months

6.0

18.0

6 months - 2 years

6.0

17.5

2 - 6 years

5.0

17.0

6 - 12 years

4.5

14.5

12 - 18 years

4.5

13.0

18 years onwards

4.0

11.0

Neutrophil reference range - Male and Female (x10^9/L)

Age

Low

High

0-2 days

2.9

14.5

3-4 days

1.8

7.2

5 days to 28 days

1.8

5.4

1 month - 8 years

1.0

8.5

8 years - 18 years

1.8

8.0

18 years onwards

2.0

7.5

Lymphocyte reference range – Male and Female (x10^9/L)

Age

Low

High

0-14 days

2.0

11.0

14 days to 1 month

2.0

17.0

1 - 6 months

2.5

16.5

6 months - 1 year

4.0

16.5

1 - 2 years

4.0

10.5

2 - 4 years

3.0

9.5

4 - 6 years

2.0

8.0

6 - 8 years

1.5

7.0

8 - 18 years

1.5

6.8

18 - 65 years

1.5

4.5

65 years onwards

1.5

4.0

Monocyte reference range – Male and Female (10^9/L)

Age

Low

High

0-5 days

0

1.9

5 days to 30 days

0

1.7

1 month - 2 years

0.1

0.8

2 - 14 years

0.1

0.8

14 years onwards

0.2

0.8

Eosinophil reference range – Male and Female (x10^9/L)

Age

Low

High

5 days to 1 month

0

0.8

1 month -5 years

0

0.7

5 - 15 years

0

0.7

15 years onwards

0

0.4

Basophil reference range – Male and Female (x10^9/L)

Age

Low

High

all ages

0

0.1

ABNORMALITY DEFINITION DIAGNOSTIC POSSIBILITIES
Acanthocytes

Red cells with irregular blunt projections

Liver cirrhosis

Neurological disorders

e.g. Huntington’s Disease

Hypothyroidism

Hereditary Acanthocytosis

Anisocytosis Variation in size of red cells

Iron deficiency anaemia

Haemoglobinopathies

Megaloblastic anaemia

Atypical lymphocytes Large mononuclear cells with  dark blue cytoplasm

Glandular Fever (EBV infection)

CMV infection

Hepatitis

Epilepsy - fitting

Bite Cells

Poikilocytes with one or more semicircular portions removed from the cell margin

G6PD deficiency

Haemolytic Anaemia
Blast Cells Very immature blood cells, not normally seen in peripheral blood

Leukaemia

Bone marrow infiltration

Marrow Dysfunction

Blood too old for cytological examination Cells show changes associated with storage

Film made over 12 hours after receipt. 

Specimen kept at high temperatures

before the film made.

Burr Cells Oval or round red blood cells with regular ‘frilly’ projections

Impaired renal function

Haemolytic Uraemic Syndrome

Disseminated intravascular coagulation

Crenated red blood cells Cells with regular spiky projections

Usually artefact due to an old blood specimen or kept in warm temperatures

Burns
Dimorphic blood film picture Two different populations of red cells present

Anaemia on treatment

Post transfusion

Sideroblastic anaemia

Concurrent iron deficiency anaemia and megaloblastic anaemia

Elliptocytes

Oval shaped red blood cells. If very long and thin called pencil cells (resemble small pencils)

Severe iron deficiency

Hereditary Elliptocytosis

Gametocytes

Sexual stage of the parasite Seen in malaria infections
Hairy cells / villous lymphocytes

Large lymphocytes with an indefinite hazy cytoplasmic membrane

Hairy Cell Leukaemia

Splenic Lymphoma with villous lymphocytes

Helmet Cells

Fragmented red blood cells that have been "scooped out" so they resemble helmets

TTP/DIC

Haemolytic Anaemia

Carcinomatosis

Prosthetic valve replacements

Howell Jolly Bodies

Small round purple bodies in red blood cells

Poor splenic function

Post splenectomy
Hypersegmented neutrophils Neutrophils with 6 or more lobes Megaloblastic anaemia
Hypochromia

Low MCH

Red cells with enlarged area of central pallor

Iron deficiency anaemia

Thalassaemia
Left shifted neutrophils

Many band neutrophils or metamyelocytes present

Infection/Sepsis

Leukaemia

Treatment with GCSF

Macrocytes/

Macrocytosis

High MCV

Large red blood cells

Impaired liver function

Megaloblastic anaemia

Raised reticulocyte count

Hypothyroidism

Leukaemia

Myelodysplasia

Metamyelocytes

Myeloid precursor cells

Infection

Marrow dysfunction

Marrow regeneration

Leukaemia

Megaloblastic anaemia

Microcytes/

microcytosis

Low MCV

Small red blood cells

Iron deficiency

Haemoglobinopathies

Some secondary anaemias
Myelocytes Myeloid precursor cells

Severe Infection

Marrow dysfunction

Marrow regeneration

Leukaemia

Treatment with GCSF

Nucleated red blood cells Immature erythrocytes (red blood cells)

Normal in neonates esp. when premature

Haemolysis

Severe anaemia

Marrow dysfunction

Marrow regeneration

Leukaemia

Ovalocytes Large oval red blood cells

Frequently associated with B12 or folate deficiency

Pappenheimer Bodies

Basophilic inclusions seen in red blood cells

Sideroblastic anaemia

Megaloblastic anaemia

Alcoholism

Splenectomy

Some hemoglobinopathies

Pincer Cells

Red blood cells with a small circular region on the periphery of the cells missing

Drug therapy e.g. Dapsone

Disseminated Intravascular Coagulation

Poikilocytosis

Irregularly shaped red blood cells

Iron deficiency anaemia

Megaloblastic anaemia

Myelofibrosis

Haemoglobinopathies

Polychromasia Variation in the colour staining of red cells indicating the presence of mildly immature red cells

Raised reticulocytes due to bleeding, haemolysis, or treatment of anaemia

Right shifted neutrophils

>5 lobes in the neutrophil nucleus

Associated with B12 / folate deficiency

Schistocytes Small fragmented red cells

Microangiopathic haemolytic anaemia

Thrombotic thrombocytopaenic Purpura

Haemolysis

Right shifted neutrophils

>5 lobes in the neutrophil nucleus

Associated with B12/folate deficiency

Schistocytes Small fragmented red cells

Microangiopathic haemolytic anaemia

Thrombotic thrombocytopaenic Purpura

Haemolysis

Schizonts

Stage at which the malarial parasite starts to divide

Seen in malaria infections
Spherocytes

Small dense red blood cells

(with no area of central pallor)

Haemolytic anaemia

Hereditary Spherocytosis

Stippled red blood cells (basophilic stippling) Red cells having many small blue dots within them

Haemoglobinopathies

Severe Alcoholism

Sideroblastic anaemia

Lead poisoning (coarse)

Polycythaemia Rubra Vera

Acute haemolytic anaemia

Bone marrow stress

Stomatocytes Red blood cells having a horizontal area of pallor across them

Liver disease

Altered plasma sodium, potassium or cholesterol levels

Hereditary Stomatocytosis

Target Cells Red cells having a central darker-staining area

Severe iron deficiency

Haemoglobinopathies

Liver disease

Tear drop poikilocytes Red blood cells shaped like tear-drops

Myelofibrosis

Severe iron deficiency anaemia

Megaloblastic anaemia

Trophozoites

Parasite stage most commonly seen in blood film.

Seen in malaria infections.

Royal Stoke University Hospital samples should be sent via the air tube system (or via portering staff in the event of system unavailability). GP samples are usually transported to Pathology via the courier driver system (scheduled collections – to discuss contact Specimen Reception on (6)74881) although there is also a specimen drop off point at the reception desk in the Main Building which is open 24 hours a day.

County samples should be sent via the air tube system (or via portering staff in the event of system unavailability). Samples can be dropped off at the Specimen Reception hatch during routine opening hours (weekdays 09:00 until 17:00). If the access door to Specimen Reception is locked then samples should be placed in the fridge provided for the purpose. This is located in the Blood Issue / Point of Care Room situated on the right hand side of the corridor, before Specimen Reception is reached. In this instance the duty BMS must be contacted via bleep 4751. Between 23:15 and 06:30 when the laboratory is not open to accept samples, samples which require urgent attention must be taken to CH Switchboard where appropriate transportation to RSUH will be organised.

RSUH

The laboratory is routinely open from 09.00 to 18.00 on weekdays. Outside these hours an out of hours service, available for contact via the bleep details below, is in operation. All specimens received in Pathology specimen reception will be prioritised and only those influencing immediate patient care will be tested immediately. The contact details for the out of hours staff is as follows:

RSUH Haematology / Blood Transfusion Biomedical Scientists – Bleep (78) 390

CH

The laboratory is open routinely from 09:00 to 17:00 on weekdays, but operates an extended day service, including weekends and Bank Holidays. Samples are accepted from 06:30 until 23:15. Samples from CH which require testing outside of these hours can be taken to Switchboard for transportation to RSUH. There is also a limited point of care service available.

CH Haematology / Blood Transfusion Biomedical Scientist – Bleep (88) 4751

The following requests will be analysed and results reported via iCM (RSUH) / ICE (CH) within a few hours provided that request cards are filled in correctly and the source of the request can be identified:

  • FBC
  • White blood cell differential
  • Reticulocyte count
  • INR
  • APTT
  • D-Dimer
  • Fibrinogen

The department will endeavour to contact the requesting source by phone in the instances listed below:

  • The BMS performing the test has agreed to phone.
  • Results alert the BMS to the possibility that the patient may need immediate attention.
  • They are urgent and ward reporting is unavailable

However, in the event that we are unsuccessful in making contact, the results will be available electronically via the ward reporting system. Alternatively the BMS can be contacted via the bleep for urgent results which are not available electronically.

Do not bleep the BMS unless the results are very urgent and need to be telephoned.

Urgent requests requiring prior discussion with BMS staff:

  • Malarial parasites
  • Sickle cell screen in appropriate patients requiring urgent general anaesthesia

Royal Stoke University Hospital:

Medical advice on Haematological, Blood Transfusion or related issues can be obtained at all times;

  • By contacting the duty clinician on bleep 723 between 09:00 and 17:30 on weekdays.
  • Outside these hours, by contacting switchboard (Internal 0, External 01782 715444), and asking for the Medical Haematologist on call.

County Hospital:

Medical advice on Haematological, Blood Transfusion or related issues can be obtained at all times;

  • In the first instance, by contacting the duty Specialty Doctor on bleep 4500 between 09:00 and 17:00 on weekdays.
  • If there is no reply, by contacting switchboard (internal 0, external 01785 257731 or 01782 715444) and asking for the duty clinician on bleep 723.
  • Outside these hours, by contacting switchboard (internal 0, external 01785 257731 or 01782 715444), and asking for the Medical Haematologist on call.

Overview

All results produced by the laboratory are dependent upon the quality of the specimens received and accompanying information. Samples should be taken into the correct bottles, which should be correctly filled (this particularly applies to coagulation tests performed from a citrate tube).

The laboratory can only safely process adequately labelled specimens and request cards. Incompletely labelled specimens and requests will not be processed.

When raising a request in iCM the patient demographics are automatically populated and the mandatory fields on the form identify the additional information required for the particular test / referral.

SPECIMEN ACCEPTANCE CRITERIA

Minimum data set for requests

1. Patient identifiable data (minimum of three unique identifiers for a patient):

  • The unequivocal identity of the patient and/or specimens using the full name of the patient, correctly spelt.  A code identifier e.g. for GUM patients or unknown A&E patients is acceptable in place of the patient’s name.
  • NHS number, hospital unit number or equivalent.
  • Date of birth.

2. Requestor details:

  • The source of the request and the destination for results.
  • The identity (and authority) of the referrer. (When using the ordering on behalf of a referrer option in iCM (RSUH), the referrers name must be recorded as part of the order process).
  • The identity of the person completing the request/ referral and, where applicable, obtaining the sample/s. (With electronic requests and referrals made on iCM the identity of the person logged onto iCM will be recorded as the person completing the request/ referral).
  • The identity of the consultant in charge of the patient (this must be completed on all paper request cards and the appropriate field completed in iCM where required). Please note, the full surname and initials should be supplied.

  1. Investigation clinical details
  • The investigation required to be performed.
  • Sufficient clinical details to demonstrate that the request is relevant and any other information relevant to the investigation requested that is essential for the correct interpretation of the request, including relevant past medical history, in particular, previous cancer and its treatment.
  • When requesting using iCM the minimum data set also includes any mandatory fields

Any request or referral submitted on a paper request card should be completed in ink and must be legible. Any paper request / referral form should be signed by an individual authorised to request the investigation.

  1. The minimum requirements for a pathology specimen are:
  • Specimens relating to the request are attached to the request label / card or other supporting documentation.
  • The specimen type is suitable for the request made.
  • The specimen container is appropriate for the investigation and is transported as defined in Policy IC20 (11).
  • The specimen is correctly stored.
  • The specimen or request label/card must be labelled with the date and time of sample collection.
  • The specimen is completed with the minimum data set (see above).
  • The specimen label matches the request label/ card with respect to the minimum data set.

In instances where a specimen label is electronically produced as part of ordering an investigation on iCM the label produced will link the specimen to the bar-coded request label produced and must be applied to the correct specimen container at the earliest opportunity.

The laboratory will not return samples for re-labelling or amendment.

PRE-ANALYTICAL VARIABLES

A number of non-pathological factors may adversely affect the results obtained from blood samples.

  • Correct sample from correct patient. Labelling of samples must take place immediately, and include positive identification of the patient.

  • Labelling - Sample & request form must be correctly filled in; the information on both should match. Incorrect or inadequate information may result in the rejection of specimens and delay results.

  • Prolonged venous stasis or poor phlebotomy technique may affect the sample integrity. This could cause full or partial coagulation of the sample which would affect both FBC and coagulation test results.

  • Haemolysis may be caused by expelling blood into the sample tube via the needle or over-vigorous mixing. This will render the sample unsuitable for FBC (cellular components will be broken down), and coagulation testing (activation of the clotting system may shorten clotting times).

  • Correct dilution - Coagulation samples tubes must be filled to the frosted line on the tube. Under or over dilution will give inaccurate results.

  • Inappropriate sample – The correct anticoagulant must be used: EDTA (purple top) for FBCs and trisodium citrate (blue top) for coagulation testing.

  • Transport and Storage - Full blood counts and coagulation samples should be tested as soon as possible after collection. Delays and incorrect storage (too hot or cold) will adversely affect results. Degenerative changes are retarded but not abolished at 4˚C.  Coagulation samples at room temperature should ideally be tested within 3 - 6 hours; INRs are stable at 4˚C for up to 24 hours and APTTs for 9 -12 hours. ESRs should be processed within 8-12 hours of collection and should not be requested as an add-on request after that time.

  • Other sampling problems which may affect results:

Vigorous exercise

Certain drug treatments

Direct sunlight on the samples

Patient having blood taken from an arm with a drip in situ

Lipaemia

  • Leaking or broken samples will not be processed.