Erythrocyte
Sedimentation Rate
(ESR)
Objective
• What is ESR
• Method of estimating ESR
• Principle of ESR
• Factor affecting ESR
• Clinical significance of ESR
• Source of errors
Introduction
• ESR is an inflammation marker used in
routine clinical practice.
• Non specific screening test indicative of
inflammation
• it is measurement of the rate (mm/h ) at
which red blood cells from aggregates or
rouleaux that sediment when anticoagulated
fresh blood is left in a vertical tube.
Introduction
• It is used an initial screening tool and also as
a follow up test to monitor therapy and
progression of disease.
• used for many years to help detect
inflammation associated with conditions
such as infections, cancers and autoimmune
diseases.
• Easy to perform. Widely available
• Inexpensive
• Unit – measured in mm/hr
Methods of Estimating ESR
• Wintrobes Method
• Westergren Method
• Capillary Method ( Micro ESR Method or
landau)
• Automated Method
Wintrobes Method
Sample & reagent
• EDTA blood
• Sodium citrate (3.8%)
Equipment required
• Wintrobes tube
• Wintrobes stand
• ESR needle or Pasteur pipette
• Timer or watch
Wintrobes Method
Wintrobe tube
• It is closed at one end ,
• length 110 mm long
• internal bore diameter 2.5 mm
Wintrobes Stand
Wintrobes Method
Procedure
• the procedure must be performed within 2 hours of
blood collection
• mix the anticoagulant blood thoroughly.
• fill the wintrobe tube by using Pasteur pipette
• place the tube vertically in a stand
• the ESR at the end of 1 hour.
Normal range
• male = 0 -- 10 mm in 1 hour
• female = 0 – 20 mm in 1 hour
Micro ESR Method
used in infants and if the blood is
inadequate.
Requirement :-
• capillary blood heel, finger tip/ toe
• landau pipette ( 0 – 50mm )
• pipette stand
• sucking device for drawing blood in the
pipette
• capillaries for blood collection
Micro ESR Method
Micro ESR Method
procedure
• Attach landau pipette to suction device
• Draw anticoagulant citrate up to the first line
• Draw blood up to second line.
• the citrate + blood into the pipette mix thorough
• Set the upper level to 0 mark at the top
• Place it vertically in the stand
• Reading after 1 hour
Westergren Method
Equipment
• Westergren Tube
• Westergren Stand
• Stop watch (Timer capable of timing
accurately 1 hour),
Westergren Tube & Westergren Stand
Westergren Tube ( Pipette)
• Glass Westergren tube measure 300 mm (30 cm) in
length
• Plastic tube are often shorter
• Graduated from 0–200 mm.
• The diameter should not be less than 2.55 mm.
• Can hold about 1ml of blood
• Open at both end
• When reusing pipettes, care must be taken to ensure
the pipettes are completely clean and dry.
Reagent & sample
1.6 ml of blood + 0.4 ml of 3.8% Tri-Sodium citrate,
principle
• when the anticoagulated blood is placed in
vertical tube and is allowed to stand, the red
blood cells will settle towards the bottom of
the tube. The speed of sedimentation of red
blood cells in plasma over a period of 1 hour
is measured RBC Column and is expressed
in millimeters. The process of sedimentation
is called ESR.
Procedure
• The blood sample must be mixed with
anticoagulant agent in this test. (Put 0.4 ml sodium
citrate + 1.6 ml blood. or put 0.2 ml sodium citrate +
0.8 ml blood ).
• Draw blood into the tube up to mark 0
• Mix gently with out shaking then put in the
graded tube and leave it stand vertically on the
stand for 1 hour.
• Record the time
• Read the amount of plasma that appeared without
moving.
Stages ( phases )
• The initial phase (stage of rouleaux formation /
aggregation) 10 min.
• The phase of rapid RBC falling ( stage of
sedimentation/ settling ) 40 min.
• The packing phase ( stage of packing ) 10 min.
Normal value
• ESR values according to age and gender .
Adult females 0 - 20 mm/h
Adult males 0 - 15 mm/h
Children(<10) 0 - 10 mm/h
Advantages & Disadvantages of
Method
Advantages
• More reliable and gives accurate result
Disadvantages
• More blood is required
• Difficult to fill the blood in tube
• Mouth pipetting may be hazardous
Factors affecting ESR
Factors affecting ESR
physiological factors laboratory factors
plasma factor Temperature
Red cell factor Time
Rouleaux formation Anticoagulant
Age Tube factor
Sex Vibration
Pregnancy Sunlight
Plasma Factor
Effect of plasma protein
•Fibrinogen, globulin and cholesterol increase
ESR by decreasing negative charge of RBC
coming together.
•Plasma albumin retards sedimentation of
RBCs
Red cell Factor
Number
- Increased in red cell mass decrease ESR
- Decreased red cell mass – increased in ESR
Size
- Microcytic sediment slowly and macrocytic sediment rapidly than
normocytic
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.
Rouleaux formation
• When RBC aggregates to form a rouleaux
and settle down the area of constituent
corpuscle,. Hence it is important factor that
affected ESR.
Age
• Infant – low
• Adult – gradually increase
• Old - higher
Sex
women has slightly higher ESR than men
because of their low PCV
pregnancy
The SER begins to increase about third the
month and return to normal about four week
after delivery.
Time & Temperature
Test should be within two hours of
collection
EDTA sample should be kept at 4 C if
delayed but should be performed within 6
hours.
Test should be done at 20 – 25 C
higher temperature cause false high result
due to reduction in plasma viscosity
anticoagulant
K2EDTA or tri-sodium citrate should be
used
heparin alter cell membrane potential and
should not be used
Position & vibration
tube should be perfectly vertical
Vibration can reduce ESR
Sunlight
direct sunlight on ESR tube increase ESR
INCREASED ESR
• Pregnancy • Acute and chronic
• Macrocytosis infection
• Tuberculosis. • Severe anemia
• Malignancies . • Multiple myeloma
• Rheumatoid arthritis • Rheumatic fever
and other autoimmune • Inflammatory disease
diseases.
• Connective tissue
disorders
DECREASED ESR
• Polycythemia
• Microcytosis
• Severe Leukocytosis
• Sickle cell disease
• Congestive cardiac failure
• Corticosteroid use
• Hypofibrinogenemia
Assignment
Source of errors