ESR

ANALYZER
ELECTA LAB
S.R.L
 Introduction
• ESR means Erythrocyte Sedimentation Rate.
• The ESR measures the rate of settling of
erythrocytes in their native anti-coagulated plasma.
• Sedimentation occurs in three stages:
1. Rouleaux formation
2. Sinking of rouleaux at a constant speed and
3. Slowing of sedimentation as the cells begin to pack.
• The length of the fall of the meniscus of the red cell
column in a unit time is the ESR.
 Mechanism of ESR
The erythrocytes in suspension repel each other
because of their negatively charged surface sialic acid
(the z potential), but increasing amounts of
asymmetric macroglobulins, mainly fibrinogen and to
a lesser extent gamma globulins, weaken the repellent
forces between adjacent erythrocytes, so that rouleaux
and aggregate formation takes place slowly. Since the
red cell rouleaux and aggregates have a relatively
large volume, they settle faster than single cells.
ESR depends on various factors
 Er y t h r o c y t e
Se d ime n t a t io n Ra t e

Plasma

Erythrocyte

T=0 T=60 min

 Plasma factors
• Proteins other than fibrinogen and c- globulins also influence
the ESR; such as albumin which retards it whereas others like
“a” and “b” globulins increase it.
• The fact that fibrinogen is one of the acute- phase reactants, it
robs the test of its diagnostic specificity and renders it
responsive and sensitive to a wide variety of abnormal states.
• Increasing IgM levels in macroglobulinemia are responsible for
maximal rouleaux formation and, at the same time, for
increasing plasma viscosity.
• The latter tends to retard the ESR and may eventually reach a
point where the viscosity exceeds the accelerating protein
effect, so that a normal or near- normal ESR results.
• The occurrence of rouleaux formation associated with normal
or near- normal ESR suggests the hyper- viscosity syndrome.
• Monoclonal gammopathy as seen in plasma cell or
lymphoproliferative disorders stimulates rouloeaux formation,
thus accelerating the ESR.
 Red Cell factors
• The size and number of erythrocytes play a minor role in
the ESR.
• When normal cells sediment, the downward force is
almost counter balanced by the upward forces generated
by plasma within the confines of the sedimentation tube.
• Changes in the shape and size of red cells eg. In
microcytosis, anisocytosis, poikilocytosis, sickling and
acanthocytosis, interfere with their ability to form
rouleaux and aggregates, thus slowing the sedimentation
rate.
• Macrocytosis and anemia accelerate the ESR, whereas
polycythemia causes it to slow down considerably.
• Heparin accelrates the rate of the fall of the erythrocytes.
 Physical factors
• The temperature, size and bore of tube, as well as, the
angle of the tube during the test influence the ESR.,
• The International Committee for Standardization in
Haematology (ICSH) has standardized the
Westergren method, because the Wintrobe method
has major drawbacks eg. The 100 mm tube length and
the narrow bore, which limit readings in excess of 60
mm/hr because of packing cells.
 Specimen
• Collect venous blood in a sodium citrate tube
and mix it well.
• Perform the test within 2 hrs. of drawing or
within 6 hrs. if the blood is kept at 4º C.
 Reference Interval

• Male = <10 mm/ hr

• Female = <20 mm/ hr
• Children (<12 years) = 3 – 13 mm/ hr.
 Interpretation
• Physiologically, the ESR is elevated in
pregnancy and in 10% of apparently healthy
children.
• The test is non specific but sensitive to
inflammation, tissue injury, auto immune
diseases and lymphoproliferative disorders.
• Since this test is not specific the C- reactive
protein (CRP) test is preferred.
 Increase in ESR
1. Infections: eg. tuberculosis, pelvis inflammatory
disease, systemic lupus erythromatosus, rheumatoid
arthritis, etc.
2. Relative increase of globulins: conditions that lead
to loss of albumin and thus to a relative increase of
globulins eg. kidney disease, chronic liver disease,
etc.
3. Absolute increase of globulins: eg. multiple
myeloma, cryoglobulinemia, macroglobulinemia
and lymphomas.
4. Extensive tissue necrosis as seen in malignant
tumors and in myocardial infarction.
5. Other conditions: eg. Pregnancy, menstruation, lead
poisoning anemia and in cirrhosis.
6. Coomb’s positive hemolytic anemia.
7. Unexplained causes.
 Normal or Near- Normal ESR

1. Haematological disorders eg. infectious

mononucleosis.
2. Localised infection.
3. Benign neoplasms.
 Decreased ESR
• Polycythemia vera.
• Sickle cell anaemia.
• Some forms of macroglobulinemia eg. hyper-
viscosity syndrome.
 Procedure
• We take Sodium Citrate anti coagulant in a Westergren
tube (disposable or glass).
• Fill the tube with venous blood up to the mark on it and
mix it appropriately.
• EDTA whole blood can also be used but the blood needs
to be transferred in Westergren tube for processing.
• Then the tube is put in the instrument and allowed to be
processed.
• In case of a difficult drawing or when blood volume is not
sufficient, the instrument can accept the sample even up to
a level of about 10 mm below the standard volume.
• The results, in this case will be compensated by the
instrument.
• The sample must be analyzes within 4 hours after
drawing. If not possible to analyze within this period,
it can be stored at 4º C for up to 8 hrs.
• Beyond the limit of allowed time, the sample tend to
decrease their ESR values and arrive to values near
zero.
• Before the analysis, the tube containing the sample
must be mixed delicately and continuously in order to
get the blood homogenous and to disaggregate the
rouleaux, which develop when the sample is at rest.
This is necessary to do a correct measuring.
 Installation
The instrument measures a physical parameter
which can be altered by various environmental
factors, thus the instrument must be placed on a
flat surface, away from heat as well as direct
sunlight and from vibrations caused due to
centrifuges.
 Power Supply
• The instrument is equipped with a universal
switching power supply therefore it must be
plugged in to ensure the correct functioning.
• Before switching on, one should check the Dip
Switches.
 Dip Switch
Nº POS FUNCTION POS FUNCTION

1 On Working time 60’ Off Working time

30’
2 On Printer enabled Off Printer
disabled
3 On Autoprint sedim. Off No sedim.
Graph Graph

4 On Temp.conversion on Off Temp.

conversion off
 Dip Switch Nº1
• Dip switch Nº1 fixes the type of result one
wants to obtain.
• When set on the “Off” position and after 30
mins of work, the device displays (and prints)
the result relative to 1 hour Westergen.
• When set on “On” position, it displays 3
results: one is referred to 1 hour Westergren
and the other to 2 hour Westergren.
 Dip Switch Nº2
• It enables or disables the printer.
• “On” enables printer.
• “Off” disables printer.
 Dip Switch Nº3
• It enables to view the printout of
sedimentation curve.
• If the device is set on the “On” position, at the
end of analysis it will print the sedimentation
curve (printer must be connected in this case).
• If the device is on the “Off” position, there
will be no printout with the sedimentation
curve.
 Dip Switch Nº4
• It enables one to use or not, the correction of
the result to a temperature (18º C).
• If one wishes to have a result referred to 18º C
set the switch “On”, otherwise keep it “Off”.
• The results will be referred to room
temperature which changes day-to-day and
therefore the results will show the effects of
this variation.
 Start Up
On switching the instrument on one will read the following display:
Sedy-12 V.1.0 (software version)
30’ working time
Results: 1 h mm
OR
60’ working time
Results: 1 h, 2 h mm.
Printer off… Print curve On…
Printer Ok…
“No message if temp. ref = Off”
OR
18º C temp. reference
27.7º C internal temp.
Starting…

Overcome this initialization phase, the instrument is ready to analyze the

samples.
 Functioning of the Analysis
• The sample must be correctly mixed and inserted in the
instrument within a minute after shaking otherwise the
sedimentation phase starts and results would be altered.
• The random access of the tubes characterizes the
instrument and differentiates it in comparison to those of
the competitors which have a batch analyzer.
• As soon as the sample is inserted in the instrument, the
infra red detecting system recognizes the starting of the
analysis and activates an independent timer for each
channel of the instrument.
• Within 3 mins the instrument starts verifying the blood
level which must be between a range of 50 and 60 mm of
height from the bottom of the tube. Beyond such limits the
sample is rejected and the instruments points out an error.
 Results
Pre indication:
Indication Range (mm/hr)
--- 1- 7
--+ 8- 16
-++ 17- 30
+++ >30
Displaying results:
The display alternatively shows (every 4 secs) 3
consecutive screens.
1- Results after 30 minutes (introduced by symbol 1H)
2- Results after 60 minutes (introduced by symbol 2H)
Indication Meaning of symbol on display
“xxx” Result = xxx
“ . ” Awaiting sample
“ >xxx” Sample value higher than “xxx”
“lev” Error: Initial level error
“rem” Error: Removed sample
• During the analysis phase, symbols are displayed
( ) which change in
sequence according to the real time at the end of the
analysis itself.
• According to the configuration of the instrument,
after expiry of working time, one or more results will
appear on the display and on the printer, if it has been
connected.
SEDIMENTATION CURVE

Sigmoid Sedimentation Curve

Sedimentation (mm)

80

60

40

20

0
0 10 20 30 40 50 60
Time (minutes)
 Analytical Performances
• Level sensor for correct blood draw Accepted range: 1.00 ml to 1.35
ml
• Real time detection system for insertion of sample
• Measuring points: Nº 10 points intervals
• Measuring range: 1 to 140 mm/ hr
• Graphic curve: On printer
• Pre- indication of the results: After 12 minutes on the display
• Mechanical/ Optical precision of
detection: +/- 0.2 mm
• Reproducibility of analysis: CV <5% (depending on the sample
value)
• Automatic temperature conversion Accepted range: 15º C to 32º C.
to 18º C
 Limitations
• Anaemia under 2 million RBCs/ cumm can give
reading problems.
• Strongly lipemic or haemolytic samples may alter
reading capabilities.
• Sedimentation rate values >140 mm/hr will be
indicated with this mark only.
• Temperatures outside the given range (15º C to 32º
C) will be accepted as belonging within that range.
Comparison between inflammatory markers

Marker Up to times Time of start Time to

normalize
CRP 100 X 6-10 h 6-10 h

ESR 5-6 X About 24 h 96-144 h

THANK YOU