erythrocyte sedimentation rate

1. ERYTHROCYTE
SEDIMENTATION RATE

2. ERYTHROCYTE SEDIMENTATION RATE (ESR)
• The erythrocyte sedimentation rate (ESR) is a
nonspecific screening testnonspecific screening test indicative of
inflammation
• It is easy to perform, widely available and
inexpensive
• used for many years to help detect
inflammation associated with conditions such
as infections, cancers, and autoimmune diseases.
• Related tests: C-reactive Protein ;
ANA; Rheumatoid Factor

3. ERYTHROCYTE SEDIMENTATION RATE (ESR)
• Anticoagulated blood is drawn up into a tube of standardized
dimensions and left in a vertical position for exactly one hour.
• After that period the point at which the red cells have separated
and settled from the plasma is recorded by reading from the
scale on the side of the tube.
• It is used as an initial screening tool and also as a follow-up test
to monitor therapy and progression or remission of disease.
• The ESR is directly proportional to red cell mass and inversely
proportional to the plasma viscosity.
• The ESR is reported in millimeters per hour

4. Principle
• The ESR is governed by the balance between pro-
sedimentation factors, mainly fibrinogen, and those
factors resisting sedimentation (negative charge of
RBCs - that repel each other) . Normal RBCs settle
slowly as they do not form rouleaux or aggragate
together. When an inflammatory process is present,
the high proportion of fibrinogen in the blood causes
red blood cells to stick to each other. The red cells
form stacks called 'rouleaux,' which settle faster.
Rouleaux formation can also occur in association
with some lymphoproliferative disorders in which
one or more immunoglobulin are secreted in high
amounts.

5. The aggregated RBCs in the rouleaux formation have a higher ratio of
'mass to surface area' as compared to single RBCs and hence sink
faster in plasma.

6. • Normal value:
ESR values tend to rise with age and are
generally higher in women. ESR is also
elevated in the black population and those
with anemia.

7. Referance Range
• Adult females 0-20 mm/h
• Adult males 0-15 mm/hr
• Children(<10) 0-10 mm/hr

9. ERYTHROCYTE SEDIMENTATION RATE (ESR)
• Although the test has been used since 1926 the phenomenon
of red cell sedimentation is still only partly understood.
• However three definite phases have been identified in the
process.
• During the first, or Lag Phase (10 min), the red cells form a
characteristic rouleaux pattern and sedimentation is
generally slow.
• The rate accelerates in the second period, the Decantation
Phase(40 min), and slows again in the final Packing Phase (10
min)as red cell aggregates pile up at the base of the tube

10. • The size of the rouleaux aggregates formed in the Lag Phase is
the critical factor affecting the final result of the ESR.
• The rouleaux itself appears to be influenced mainly by certain
plasma proteins including fibrinogen, IgM and alpha2-
macroglobulin.
• From the above it can be seen that the sedimentation 'rate' of
the red cells is not linear.
• Further, the time taken for each of the three phases will differ
between patients.
• Therefore no attempt should be made to 'estimate' the result at
1 hour by doubling the value at 30 minutes or multiplying by
three after 20 minutes

11. ERYTHROCYTE SEDIMENTATION RATE (ESR)
• Any condition that will increase rouleaux formation will
usually increase the settling of red cells.
• Specimens that are not properly anticoagulated will
also affect red cell settling.
EDTA is the recommended anticoagulant

12. ERYTHROCYTE SEDIMENTATION RATE (ESR)
• Westergren method
• Wintrobe method
• Studies have shown that the Wintrobe method was
found to be misleading in some important cases
• As a result, the Westergren method is most widely
used

13. Westergren Method
• Requirements:
1. Westergren Pipette
2. Westergren Stand
3. Anticoagulant
• Westergren pipette is open at both the ends.
It is 30 cm in length and 2.5 mm in diameter.
The lower 20 cm are marked with 0 at top and
200 at bottom.
• The anticoagulant used in this method is 3.8%
tri-sodium citrate solution. 0.4 ml of tri-
sodium citrate is added in 1.8 ml of blood.

14. PROCEDURE – WESTERGREN METHOD

15. PROCEDURE – WESTERGREN METHOD
• 1. Mix the EDTA tube on the rotator/mixer for a
minimum of 5 minutes.
If the sample has been refrigerated, allow 30 minutes
for the sample to come to room temperature before
proceeding.
Hold the filling reservoir and shake downwards with a
flick the wrist to force the saline to the bottom
Keep upright and remove cap

16. PROCEDURE – WESTERGREN METHOD
• 2. Add 1ml well mixed EDTA whole blood to the filling line of the
reservoir.
• 3. Replace Cap
• 4. Gently mix by inversion (minimum of 8 inversions)
• 5. Place on flat surface an make sure that all the blood return
back to the bottom of the reservoir

17. PROCEDURE – WESTERGREN METHOD
• 6. Hold the reservoir firmly in one hand and the Dispette tube in the
other hand with the 180 mark towards the bottom
Penetrate the cap membrane and stop
• 7. With gentle movements, continue to penetrate the reservoir
towards the bottom
Making sure that the blood is rising to the top until it reaches the
grommet at the zero mark
When the Dispette is fully inserted, any extra blood will be
accommodated by the plugged overflow chamber

18. PROCEDURE – WESTERGREN METHOD
• 8. Place the fully assembled Dispette
apparatus in a level stand at 90
degrees to the stand
Read and record the results in
millimeters at exactly one hour after
settling upright (distance which the
cells have settled)

19. Technical Errors
• 1. Tubes not filled properly will yield erroneous results.
• 2. Refrigerated specimens must come to room temperature for 30
minutes prior to testing.
• 3. The ESR rack must be on a level surface and free of vibration.
Vibration can cause a falsely increased ESR.
• 4. Cold agglutinins can cause a falsely elevated ESR.
An ESR can be performed at 37 degrees C (incubator) for 60 minutes with
no ill effects.
• 5. Red cell shape and size: Specimens containing sickle cells,
acanthocytes, or spherocytes will settle slowly and give a decreased ESR
• 6. Increased rouleaux formation, excessive globulin, or increased
fibrinogen will increase the ESR.

20. Technical Errors
• 7. Specimen must be free of clots and/or fibrin.
• 8. A tilted ESR tube gives erroneous results.
• 9. Hemolyzed samples are not acceptable.
• 10. Specimens older than 24 hours are not acceptable.
• 11. Do not pick up the stand to read results as this will affect other
tests in progress.
Bring the eye to the level of the top of the red cells to read
accurately from the scale
• 12. Results must be read at exactly one hour, otherwise the cells
with continue to sediment resulting in higher results

21. CONDITIONS ASSOCIATED WITH INCREASED ESR
• 1. Kidney diseaseKidney disease
• 2. Pregnancy2. Pregnancy
• 3. Rheumatic fever3. Rheumatic fever
• 4. Rheumatoid arthritis4. Rheumatoid arthritis
• 5. Anemia5. Anemia
• 6. Syphilis6. Syphilis
• 7. Systemic lupus erythematosus7. Systemic lupus erythematosus
• 8. Thyroid disease8. Thyroid disease
• 9. Elevated room temperature9. Elevated room temperature
• 10. Ischemic stroke10. Ischemic stroke
• 11. Temporal arteritis11. Temporal arteritis

22. Some conditions with very high ESR >100
mm/hr
• Multiple myeloma
• Connective tissue
• Autoimmune diseases
• Tuberculosis
• Malignancies
• Severe anemia

23. PATHOLOGICAL CONDITIONS ASSOCIATED WITH ESR
Decreased ESR
• 1. Congestive heart failure
• 2. Hyperviscosity
• 3. Decreased fibrinogen levels
• 4. Polycythemia
• 5. Sickle cell anemia
• < 0.5 mm/hr

24. ERYTHROCYTE SEDIMENTATION RATE
THE END