Infection or Inflammation? The Quick & Dirty on CBCs

Okay,
good morning everybody. It is morning. It's 10 o'clock central time here in Texas, the one that's actually been really nice. Uh, but in the chat you just tell me where you're from, what's going on, uh, what new information we have. And we're going to get started here in just a second. Cool. Uh, we kind of posted this session a little bit last minute and I'm on one of the throw some, some more lab stuff on there. Um, some more labs, cause I know you guys like the CBC stuff, so we're going to get started with that. Just one second.
Cool. Amul what's up St Louis, Missouri, Missouri, if you're from the south of Missouri or Missouri, if you're in the, uh, from Sweden. Excellent. We have somebody from Sweden. That's awesome. Cool. All Right Maria, it's really important. I want to, um, there's a thing, a cheat sheet. I want to refer you to, uh, hear it a little bit and I'll put it in the chat. But what it is is it's actually an international unit kind of thing. Um, it helps with some conversions cause not everything is, is the same. Um, so it has like international conversions. So I'll make sure I put that in the chat for you. But let's get started. Um, so we're going to talk, I'm going to share my screen, so give it a second. If you can't share the screen if or if you can't see the screen, if you can't hear the audio, it's almost important to log out and log back in and make sure your settings are all right. But then we'll get started with it. So let's share my screen. We're going to do screen 2:00 AM all right, everybody should see something that says CBC, the four one one. Make sure you can see that here. Cool. All right, so, um, let's see if I think I can control it.
Maybe
I want them to be kind of strange. Bear with me. I'm going to do one thing. One quick second. Good.
Yes.
One sec guys.
Bear with me. I'm trying to make it to work and actually control the slides cause it's not wanting to cooperate with me in, there you go. Cool. All right, let me perfect. All right, so let's talk about the CDC. The four one one. So the thing about the CDC is it includes a lot of different things. So in the CVC, actually let me back up in the chat. Tell me what do you, what do you guys think is included in that? CVC? Just real quick. Just tell me the things that you think are uh, so white blood cells. I'll say you guys. Cheating. Cheating. Just kidding. Um, so white blood cells, platelets, red blood cells, a hematocrit, red blood cells. Cool. Heme, uh, hemoglobin is another one. Uh, so let's get into it. The first thing that we're going to look at with, um, to CBC is white blood cells, white blood cells.
This is your normal range or half to 10, uh, 2000 cells per microliter. And we'll get into kind of the differential cared a little bit and what all these mean. But white blood cell is, you're going to be things that you look for with a different types of inflammation, infection and uh, let's do some drawing. So the white blood cell. So these are things we look for. So infection, we'll look for inflammation. And then we also look for, um, leukemia is another type. That's another thing we'll look for. So we'll look for these three things with your white blood cells. So with your red blood cells, it's another one we're going to look at on this is what red blood cells. Now if you'll notice that there is a difference between um, uh, the production between genders. So men and women are willing to produce slightly different, um, amounts of red blood cells.
And this is going to impact your hemoglobin and Hematocrit as well. But men produce slightly more. Um, and I would have to look up this specific reason, um, cause I don't know off the top of my head but I would have to look that up. But just know that men produce slightly more than women and like I said, it's going to affect that regulates or the hemoglobin and hematocrit. So like I said, hemoglobin is going to be slightly higher. Um, who can tell me why hemoglobin is important and I'll give you just one second in the chat.
Okay.
Anybody tell me why the hemoglobin is important? Like, why, why we specifically look at hemoglobin carries oxygen. Yeah, that's, that's where we want to look at that we want to pay attention to a hemoglobin. Hemoglobin is going to be one of those, those quick references that we can look at. And um, when we look at that we can say, okay, does my patient by patient have a, a blood loss issue? Do they have a rue blood cell production issue? Um, do they um, are we worried about maybe some sort of oxygen mismatch? Cause your hemoglobin can be normal. And let's say you have, uh, let's see, high carbon poisoning. Well remember your, your hemoglobin can be normal, but because uh, uh, carbon monoxide has a higher affinity for hemoglobin. I'm sorry, I said to migrants, he was a little bit, has a higher affinity for carbon monoxide than it is oxygen.
So carbon monoxide is present. It's actually going to attach, uh, to that. Um, so let's say you have your, let's say you have certain seizure red blood cell rate and say this is your hemoglobin molecule or right here, this your hemoglobin receptor right here. Well, you had cdot and then you have, oh well what's gonna happen is this is gonna come, uh, this is going to bind and it's going to take up that receptor. So your oxygen can't go anywhere. Well, what you have to do for those patients, and this is why it's really important for patients that are on a severity of carbon monoxide poisoning to get out of the, just just by supplementing them with oxygen does not actually correct the issue. You actually have to remove and decrease the amount of carbon monoxide so that carbon monoxide can't go and bind. So now the hemoglobin, um, your red blood cells are going to get, uh, so this is your new one and all of a sudden there's, there's only oh two around or your [inaudible] is going to attach instead. So that's why that, that's why you have to understand what the importance of you a little bit versus like Hematocrit is. So let's get to [inaudible]. Um, well one thing you've probably noticed with matter could here is it's actually in a percentage. And the reason it's a percentage is if we, um, let's say that this is a test dude, sorry. Had too much coffee, you could see me shaking. Um, so if this is change colors, I can change.
Um, that's good to one sec.
Okay.
Okay. So what we look at with, um, with an amount of credit is it's actually a percentage because you're measuring the amount of, uh, red blood cells up to total blood volume. We got to away, hold on one second.
Okay.
On my opinion. Wait, hold on one second. That's cool. The orange orange. Oh, I can see Martin. Okay, cool. Um, so this is, so let's say that this is the plasma
and this is the red blood cells. The red blood cells take up a percentage and a good, a good, just general number for this is going to be like 45% general based on men and women. Just if you say, Hey, what's it normally? About 45%. They're going to vary slightly again, because they produce different amounts. But the reason it's a percentage is you'll see that rebel, it's those take up about a 45% of that. So if you look here, here is a total, uh, total blood volume. You'll see that the red blood cells take up that percentage. So that's why it's important. So you can look at this and say, you can take a snapshot of a Hematocrit and or you can get your those lab results and say, okay, my patients, uh, my patient's hemoglobin is 15, and, uh, my patient's Magritte is 45. So those are both normal nights. Now kind of a good rule of thumb is your hematocrit, is it usually about three times your, uh, hemoglobin amount? So if your hemoglobin is a 10, expect your hematocrit to be about 30%. This is not like a hard rule, but it's kind of a general rule of thumb. So if you're ever like, oh, what is, what should it be? So the patient has a hemoglobin of uh, let's say a patient's hemoglobin of seven, what would I expect their hematocrit to be?
21. Yup. Kind of good rule of thumb and a patient with a hemoglobin is seven in America at 21 should be getting what? Who can tell me what if I have a patient with a hemoglobin is seven. Yeah. I'm getting some, some packed red blood cells. Yeah. Cause they, they need a transfusion. All right, cool. Let's move on to the next one. I'm platelets, platelets. Um, I'm going to say something really important about quiz cause I think, uh, I think it's a really important rule you to pay attention to what your labs is and what your facility policy says about what is considered a low platelets. Platelets are responsible for clotting. And I've seen a normal be 150 to 400.
Yeah.
Sorry. I've seen normal be uh, a hundreds of 400. I've seen normal be 104 50. I've seen all of these things. General, uh, you know when we're concerned is for a patient that has less than a hundred, 100,000 cells per microliter. That's where, where we're going. But what Mike main concern here is what does that lab in the facility policy say? What's a critical lab? Is a critical lab less than 80,000? Is it critical lab less than 50,000? Um, at what point am I you to pay attention and, and, and get in touch with the provider? That's what I need to know about platelets. Oh, differential. This is where we get into the fun stuff with a CBC is we can actually say, hey, my patient has some something going on. What do we need to do about our patient? So your differentials do several different things. Um, the first thing is that you're going to see them in percentages and you're also going to see them in absolute values.
The reason percentages you guys see them more commonly is they're going to give you some more information in terms of, uh, kind of general guidelines. Like, if I know that my neutrophils and we'll get to what their functions are here in a second, but my neutrophils are 40 to 60, um, and I get an extra f. Um, let's say my patient's got an elevated white count and uh, neutrophils are taking up 80%. So if they have an increased white blood cell, oh my goodness, and increased white blood cell count and they have this increased neutrophilia, that means that the most likely caught and the most, uh, likely cause of that, uh, increase in white blood cells from those neutrophils. And then I should pay attention to my patient and be able to derive some information from that lymphocytes. Same thing, 20 to 40%. You're gonna see less lymphocytes and neutrophils, [inaudible] less monocytes. The neutrophils and lymphocytes, eosinophils and basophils are going tape take up a small portion of, of that differential. So what do all of these mean?
First off, we look at the differential. Neutrophils are responsible for inflammation. So if you have a patient that has maybe some sort of trauma and their white blood cell count as up, expect to see this guy expect to see a neutrophilia. So the, if we look at the next one, lymphocytes, this is the one that's going to be responsible for infection. So if I have a patient that's going to increase white blood cell count and let's say their lymphocytes are up and their uh, and their, and their neutrophils are up, I could expect to see that. Maybe this is like a sub. Like for instance, let's say you get it meanwhile and she's 94, and she was out in her garden and she scratched her leg on a bush and now her leg is hot, it's swollen, it's red. And uh, you've got this increased white count and you've got the increased neutrophils and you've got these increased lymphocytes.
You can expect that those numbers are going to be a really high because maybe she's got some sort of cellulitis or some sort of infection. That's what we're expecting. Monocytes, same thing. We're expecting different types of, we're expecting the cause of macrophages are responsible for going to the side of the bacteria, the little bacteria that right. And then you have this macrophage that comes in and engulfs them and destroys them. That's what the macro function does there. It's going to be a type of immune response that you're going to see kind of later in the game. So prolonged infections, you'll see these macros, these macrophages, uh, show up. So you'll see an increase in the monocytes, especially if you're trending them, you'll start to seem them up. The big one here is the eosinophils and basophils because they both are responsible for inflammation and allergic response.
So you can have them both go up and asthmatic patients. But let's say you get some sort of patient that has maybe nurses, there's a causes, which is that, uh, it's because of like the parasite in under cooked pork and you have this increase in this white blood cell count and all of a sudden you notice these eosinophils are like 10%. That means that holy crap, we have some sort of parasitic infection. So the big thing that, the big takeaway here is that eosinophils and basophils are responsible for your inflammatory responses, like allergic reactions, your lymphocytes, and monocytes are you going to be at once you're gonna see an infection. If you, if you have an increases in those white blood cell counts and they're responsible for, uh, that, uh, and you see like as a trauma or something, you'll have these neutrophils go in. But the other one is, hey, it's kind of a weird situation. You really don't see it as eosinophils go up, uh, very often. So just pay attention to those. All right, so let's do a case study. I know you guys like these. So let's say you have a 35 year old male. He's admitted for abdominal surgery. He's two days status post ends with s. P means ms p means status posts.
Yeah.
Meaning he had surgery two days ago. You'll see this very commonly, for instance, plastics, exploratory laparotomy for small bowel obstruction. That's what SBO stands for. So he came in, he had an obstruction in his bowels. They took him in. They didn't explore as a open Emma. They explored what was going on. Um, he's currently in the ICU. Here are his current complaints. He's got fatigue, he's got pallor, so he doesn't look great. His heart rates slightly elevated. His blood pressure is 94, 49. Um, his temp is normal. This is in Celsius. He's got an Spo, two 94 K he's complaining of not feeling great. He's going to increase heart rate and his blood pressure's just dropped a little bit. What do you think's going on with him?
So in the nursing process, we're, we're, we're thinking about it. So we're assessing our patient so we can see that as heart rates, his vital signs are low. Okay, cool. The next, the other part of assessment. And so when you can take this in with you to the in clinic. So let's say you get this without these things, you can make assumptions, but we want to complete that assessment. And so here we're going to take a look at these white blood cells, or we're going to take a look at a CBC, CBC, his white blood cell count is normal, so we don't need to worry about some sort of infection. Uh, the other thing that would indicate infection, maybe be this, like if you had an increased temperature and his white count was up, I could account for that increased heart rate with an increased temperature.
And maybe an infection may be suspicious, but he's not complaining of that. But his, his red book, his red blood cells is only 1.8 million. Normal is 4.5. We see that that's a low number. Hemoglobin 6.5, that's definitely a low hematocrit. 19.5 platelets. I'm not worried about his platelets because he's clotting normally. So you guys say that he's possibly bleeding. I would agree with you. Um, what do you, what do you guys think would be the next step? So let's go to that nursing process. So we've assessed our patient. Um, what do you think would be okay, so we did. So the assessment is, hey, cool. Uh, we see you guys vital signs. We've got this, we've assessed our patient. He's is, he's got a compensatory, a Tek, a cardio, which is totally normal, um, for this situation. So we go to our diagnosis, which is what's wrong with our patient. So you guys say he's that he is, uh, bleeding. All right? So what the next step is going to be p stands for what? Planning. Perfect. And where, what are we gonna plan to do for this patient?
Okay.
So Samuel says, give her a motel. Do you have any, anybody else? Raise fluids. Stop bleeding. Get red cells checked verse. Okay. All right. So in order to do red blood cells, what do I need before I do regular tests?
Okay,
let's talk about transferring just for a second.
[inaudible]
okay, so we had a crisis. [inaudible]
okay.
That's one thing we have to do theoretically. So C, so Samuel says, but what do you, but you should have that for surgery, right? So theoretically, but that means that you're doing what? That you're making an assumption. And if we're assuming there's an old adage, which is, yeah, yeah, yeah, yeah, yeah. Right. So we can't think about it like, Hey, he should have, but that doesn't always happen.
I'm ready. And remember, he's two days status post external exploratory laparotomy. Typing screens are only good for up to 72 hours. So if he had hit his type and screen three days ago, you may have already expired that. So now the type of screen is not done. So even if he, let's say he did, and that's why it's, it's important to like not assume things. So if we say, all right, look, he, he came in for a small bowel obstruction. Um, he could have sat there for a whole day before they did anything. Um, and then they finally did decide to do an explorer for a laparotomy cause when they come in and out. Yeah. So what is, what else could we do in the meantime? These are, these are in class questions. These are more, uh, like real life questions. I want to, you know, we, it's important that you, we prepare you for the inklings, but we also wanted to make sure that you are prepared for some real life situations. So the other thing about that is, is all right, so we're going to plan, so he should, if he has it, if he's in the ICU, Samuel said start on eight. So Samuel, do you think a patient in the ICU is going to have lines already?
This guy should have lines. This guy. Yeah. Well, typically you got me back, you got me back. Fair enough. I'm sure. But I would be assuming, so if a patient's in the ICU, most patients are typically gonna handle lines. So in planning, what you want to do is, what can I do in the meantime? If I walk away from my patient, I know that they're going to be sick or I know that the intervention that I'm doing is going to improve their outcomes. So a couple of things that we can do here. Number one, we're gonna need to notify their provider, but that's not the first thing you need to do. And I know that you guys kind of have that in the back of your mind, but we should be taking them back to the surgery. We should be doing something else. Right? The first thing we need to do is his, if you guys do his math, which is what we're worried about for ICU patients, this is going to give you a little insight and system critical care yourself. We do 90 plus 49 the math 90 plus 49 plus 49 which is the formula for a map for your mean arterial pressure, which is what we were. So map we want greater than 60 to profuse our kidneys.
That's what we want. We want it. We're going in sixties and 90 plus 49 plus 49 which the, the formula for getting map is as systolic blood pressure plus two times the I stop blood pressure divided by three.
Yeah,
so if you have your notes, I want you to guys, I want you guys to take this. So 90 plus 49 plus 49 gives you one 88 divided by three being at 62
that makes 62.67. Cool. So our map is still good. I'm not worried about his kidneys not getting perfused at this very second, but he is going the wrong direction. What I want to do is I want to help him out so I can do, I can do a couple of things. The first thing I would want to consider is maybe a bolus of some sort. I want to help increase the pressure because I don't want to overwork as hard. I don't want to get into this. Uh, this negative cycle of his heart rate goes up, his blood pressure drops, his heart rate goes up, blood pressure drops. Now we get into a shock issue. Now we're not really perfusing other organs. Now we're starting to not perfuse the, um, we could be causing some ischemia and about this. These are the things we want to think about.
So, hey, we're going in another direction. What can I do while I can support my patient? I can make sure that, um, I can give them a bolus. Uh, we can also, and then we can say, okay, let's get the bullets, see what happens and make sure that you're on outputs. All right. And then we're going to go to the provider and see where they're going to want to go. Your next steps are probably gonna be maybe a CT scan. Um, he's not doing terribly well. You also probably do that typing cross. And then the other thing is you may give him some packed red blood cells, but the other thing we want to do is we can continue to get these pipe pink red blood cells, but you will also need to plan for maybe start a war. These are the things you need to be thinking about in the back of your head.
Okay. Possible CT possible probable type and screen, probably red blood cells, maybe a Bolus in the meantime cause I can do this and not cause any harm to the patient and also potentially go to oir. So Alara also means I need to check for consents, any demand and what is my policy on consent. Do I need to take him back? Do our consents good for a certain amount. Like we had a policy that if a patient had an o or like seems like they would have to have a new consent, but like blood transfusions related, they wouldn't need necessarily need a consent for the blood transfusion. So there's lots that goes into it. So when you're planning, these are the things we need to be thinking about. All right, let's do one more.
Okay.
Okay. This is an 18 year old female complaining of a fall from the balcony. Radiograph confirms the broken distal Femur. So we have a broken leg. Her complaint is pain and lay heart rate is elevated, blood pressure is elevated, temperature is normal. Spo Two is 99. Cool, great. That's fine. Heart rates up, blood pressures up in, I look at my, my, uh, let's look at my CBC. Cool. CBC is 14, 14,000. That's slightly elevated. And then we look at, okay. And we look at all of our other stuff. All right, cool. That looks great. That looks great. You put this, you're good. Uh, now I come down here and look at the differential. So my differential says my neutrophils are high. Why are my differentials high? Perfect. All right. Exactly. This is an inflammatory process that makes it exactly what I would need patient. So I want you guys to think about these. Um, I'm actually going to hear in about two minutes. I'm gonna, I'm going to wrap this up cause I have one more session where we're gonna talk about the pharmacology, uh, the socket method of pharmacology. And so if you guys want to hang out for that, that'd be awesome. Um, you guys did extremely well today. I can, I've got time for like one question and that's about it.
[inaudible]
you guys have any questions? I can answer them right now.
Okay.
Stop sharing my screen.
[inaudible]
right. All right guys. Cool. Well thanks for hanging. Uh, we're going to do, like I said, we're going to go into that, that sock method. Um, we're going to talk a little bit more about, um, kind of what's involved with the sac method. Um, and the next session, and that should start in just a few minutes. So if you guys don't have any questions, I will see you there. And then also, if you're there and you have questions about this, I'll probably have a little bit more time to hang out and answer those questions for you. All right guys, I'll see ya in a few.