1. Objectives � What is ESR? � Explain the principle of erythrocyte sedimentation.

� Discuss mechanism of ESR? � What are the factors affecting ESR? � What are
methods of estimating ESR? � What is the clinical significance of ESR? � What are
the source of error while doing the test?
2. ESR � Erythrocyte- red cell � Sedimentation- settling � Rate- amount in a given
time
3. Introduction � Also k/a �sed� rate � Non specific test indicative of
inflammation � It is used as an initial screening tool and also as a follow-up test
to monitor therapy and progression or remission of disease. � Easy to perform,
inexpensive � Inexpensive making it a widely used screening test.
4. � Inexpensive making it widely used screening test � Measure- how much red cell
will settle in a given time � Unit-measured in mm/hrs Why is the �hr� bit
important?
5. Principle When the anti coagulated blood is allowed to stand vertically, the red
cells will settle towards the bottom of the tube till they form a packed column in
a given interval of time. The process of sediment6ation is called ESR.
6. Mechanism � ESR is determined by the interaction between factors that promote
(fibrinogen) and resist (negative charge of RBCs - that repel each other)
sedimentation. � Normal RBCs settle slowly as they do not form rouleaux. Instead,
they gently repel each other due to the negative charge on their surfaces. �
Rouleaux are stacks of many RBCs that become heavier and sediment faster.
7. Mechanism � Plasma proteins, especially fibrinogen, adhere to the red cell
membranes and neutralize the surface negative charges, promoting cell adherence and
rouleaux formation � The ESR is directly proportional to the weight of the cell
aggregate and inversely proportional to the surface area
8. Stages � Stage of rouleaux formation/aggregation- 10 min � Stage of
sedimentation/settling- 40 min � Stage of packing- 10min
9. Factors affecting ESR Physiological factors � Plasma factors � Red cell factors
� Rouleaux formation � Age � Sex � Pregnancy laboratory factors � Temperature �
Time � Anticoagulants � Tube factor � Tilting of tube � Vibration � Sunlight
10. Plasma factors � Fibrinogen, globulin and cholesterol increase ESR by
decreasing negative charge of RBC. Negative charge prevent the RBC coming together
� Plasma albumin retards sedimentation of RBCs. � Lecithin- retard ESR
11. Red cell factor � Number: � Increased in red cell mass- decrease ESR �
Decreased red cell mass- increased in ESR � Size: � Microcyte sediment slowly and
macrocyte sediment rapidly than normocyte
12. � Shape: � The shape of the erythrocytes can also affect the ESR. � Sickle cell
retard ESR because abnormal cell hamper rouleaux formation � Spherocytic cells also
sediment at a slow rate Red cell factor
13. Rouleaux formation � When RBC aggregates to form a rouleaux and settle down the
area is much less than sum of the area of constituent corpuscle � Hence it is
important factor that increase ESR
14. Age � Infant- low � Adult- gradually increase � Old- higher
15. sex � Women has slightly higher ESR then men because of their low PCV.
16. Pregnancy � The ESR begins to increase about third the month and return to
normal about four week after delivery.
17. Temperature � Test should be done at 20-25� C � Higher temperature cause false
high results due to reduction in plasma viscosity � Always bring refrigerated blood
at RT � Rise in every 3� ESR increase by 1mm
18. Time � Test should be done within two hours of collection � EDTA sample should
be kept at 4�C if delayed but should be performed within 6 hours.
19. Anticoagulant � K2EDTA or tri-sodium citrate should be used � Heparin alter
cell membrane potential and should not be used
20. Tube factor � ESR is greater with longer tube � Inner diameter should be 2.5mm
or more to overcome capillary attraction
21. Position of tube � Tube should be perfectly vertical � ESR increase as the RBC
slide down along the lower side � Angle of 3� from vertical can increase ESR by 30?
22. Vibration � Vibration can reduce ESR
23. Hemolysed or clotted sample � It retard ESR � Clot trap fibrinogen hence, no
rouleaux formation occur
24. Sunlight � Direct sunlight on ESR tube increase ESR
25. Other factors � Drugs such as dextran, methyldopa, oral contraceptives,
penicillamine procainamide, theophylline, and vitamin A can increase ESR, while
aspirin, cortisone, and quinine may decrease it.
26. General assumption
27. Clinical significance Increased ESR � Pregnancy � Anemia � Macrocytosis �
Inflammatory disease � Acute and chronic infection � Multiple myeloma � Rheumatic
fever � Rheumatoid arthritis � Anemia � Tuberculosis � Systemic lupus erythematosus
Decreased ESR � Hyperviscosity � Decreased fibrinogen levels � Polycythemia �
Sickle cell anemia � Spherocytosis � Microcytosis
28. Methods of estimating ESR � Wintrobe�s method � Westergren method � Modified
Westergren method � Automated method
29. Wintrobe�s method Wintrobe tube: � It is closed at one end � length- 110 mm
long � Internal bore diameter 2.5mm. � Tube is calibrated on both sides: 0-10 and
10-0.
30. Requirement Sample � EDTA blood Apparatus required � Wintrobe tube � Wintrobe
stand � ESR needle � Timer The procedure must be performed within 2 hours of blood
collection.
31. Procedure � Mix the anti coagulated blood thoroughly. � Fill the wintrobe tube
by using Pasteur pipette upto mark 0. � Place the tube vertically in a stand. �
Note the ESR at the end of 1 hour.
32. Normal range � Male=0-10 mm in 1st hour � Female=0-20 mm in 1st hour
33. Westergren method � Simple and widely used method � Method recommended by ICHS
34. Requirement Sample � Trisodium citrated anticoagulated blood � 1.6 ml of blood
is mixed with 0.4 ml of TSC Apparatus � Westergren tube � Westergren stand � Rubber
bulb � Timer
35. Westergren tube � Length= 30cm � Internal bore diameter= 2.5mm � Can hold about
1ml of blood � Open at both end � Calibrated from top to bottom: 0-200mm
36. Procedure � Mix the blood thoroughly. � Draw blood into the tube up to mark �0�
with the help of rubber bulb. � Wipe out blood from bottom of the tube. � Transfer
the tube to westergren stand and stand it vertically. � Record the time and take
reading.
37. Normal value � Male= 0-5mm in 1st hour � Female=0-7mm in 1st hour
38. Advantages � More reliable and gives accurate result Disadvantages � More blood
is required � Difficult to fill the blood in tube � PCV cannot be done � Mouth
pipetting may be hazardous
39. Modified Westergren Method � EDTA blood is used instead of citrate. � 2ml of
EDTA blood is diluted with 0.5 ml of 3.8% TSC or 0.85% NaCl � Undiluted blood gives
poor precision.
40. Automated method � Ves-Matic � ESR STAT-PLUS � SEDIMAT � Zeta Sedimentation
41. VES-MATIC 20 instrument � It is designed to measure 20 blood sample. � Result
are comparable to Westergren method � results are available in approximately 22
minutes.
42. Blood is collected in a special cuvette Sample is mixed by instrument Sample is
allowed to stand at 18� slant from vertical Opto-electrical sensor measure ESR Data
are elaborated and printed Working principle:
43. ESR STAT PLUS � It is centrifugation based method. � Provides results in 5
minutes.
44. Working principle: Sample is placed in centrifuge Infrared laser tracks the
erythrocyte plasma interface and takes multiple measurements Linear portion of
sedimentation is identified Software algorithm to determine ESR result
45. SEDIMAT � The filled Sediplast Westergren pipet is placed into the SEDIMAT
automated ESR reader, which accelerates sedimentation under controlled conditions.
� The reader displays the results of each sample on an LCD display after 15
minutes. � The results are also stored in memory and can be printed out.
46. Zeta Sedimentation Ratio � The ZSR is performed using a special, small-bore
capillary tube that is filled with blood and spun for 3 to 4 minutes in a special
centrifuge called the Zetafuge � Centrifuge alternately compacts and disperses the
RBCs under standardized centrifugal force � Tube is then read on a special reader
to obtain a value called the zetacrit � It is rapid, corrects for anemia, and
requires only a small blood sample, which is desirable for pediatric patients
47. Advantages of automated methods � Save technician time � Provide increased
safety because the need for sample manipulation is decreased � Interface with
laboratory information systems (LIS) � Use smaller sample volumes � Provide more
rapid results
48. Source of error � Improper ratio of blood and anticoagulant. � Hemolysed
sample. � Clotted blood. � Presence of air bubbles. � Error due to sunlight,
vibration, small bore size, dirty and wet tube. � Delay in performing the test.
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