Aim: To Determine Erythrocyte Sedimentation Rate (ESR)

Aim: To determine erythrocyte
sedimentation rate (ESR).
ESR- It is the rate at which the RBC’s settle down in anti-

coagulated blood. It is expressed as mm at the end of first
hour.
• Principle: In the circulating blood, red cells remain uniformly
suspended in the plasma. However, when a sample of blood in which
anti-coagulant is added is allowed to stand in a narrow vertical tube,
RBC (specific gravity is 1.095) being heavier than plasma (specific
gravity=1.032) settle at the bottom of the tube.
• Mechanism of ESR: It takes place in three steps.
1. In the first stage, RBC piles up and rouleaux that becomes heavier
during the first 10 to 15 minutes.
2. During the second stage, the rouleaux been heavier sink to the
bottom. This stage lasts for 40 to 45 minutes.
3. In 3rd stage, there is packing of massed bunches of red cells at the
bottom of the blood column. This stage last for 10 to 12 minutes.
ESR is determined by two methods:
• Westergren’s method: This is the standard method.
• Apparatus:
1. Westergren’s tube or pipette- it is a 300 mm (30cm) long pipette
graduated from 0 to 200 mm, from the above downwards with an interval
of 2.5 mm.
2. Westergren’s stand- it is the tall rack designed to keep westergren’s tube
in vertical position. It can hold 6 tubes at a time. There is a rubber cushion
at the base, the pipette is made to rest. There is a screw cap that slips over
the top.
3. Empty vial and disposable syringe.
4. Sterile swab with 70% alcohol.
5. Anticoagulant- sodium citrate (3.8% solution).
4 parts of the blood mixed with 1 part of anticoagulant.
• Procedure:
1. Draw 2 ml of venous blood and transfer it into a vial containing 0.5ml
of 3.8% sodium citrate solution. This will give blood : citrate
concentration ratio of 4:1. Mix the contents by inverting it or by
swirling the vial. Do not shake the vial as it will cause frothing .
2. Suck the citrated blood in the westergren’s pipette up to zero mark
and immediately close its upper opening with a thumb to prevent
blood from running down.
3. Then press the lower end tightly on the rubber pad or cushion and
fix it in an exactly vertical position with levelling screws in the
Westergren’s stand.
4. Note the time and take the readings of ESR at the end of one hour.
• Normal values:
Males- 3 to 9 mm at first hour.
Female- 5 to 12 mm at first hour.
Advantages:
It is more sensitive method since the tube is sufficiently long and its
diameter is also longer which is important in which ESR is high(>80mm)
Disadvantages:
Citrate solution dilute the red cells which by itself tend to raise the
ESR but the fibrinogen and globulin of plasma are also diluted which
tend to lower the ESR. Thus the two factors tend to neutralize each
other.
• Wintrobe’s method:
• Apparatus:
1. Wintrobe’s tube- it is a thick walled cylindrical tube 11 cm long with
a uniform bore diameter of 2 mm. It’s lower end is closed and flat.
Tube is calibrated from 0 to 10 cm from above downwards on one
side of the scale (for ESR) and 10 to 0 cm on the other side (for
PCV).
2. Wintrobe’s stand- it can hold up to 3 to 6 tubes of at a time. The
tubes are held vertically throughout the test.
3. Pasteur pipette with a long thin nozzle.
4. Disposable syringe and needle.
5. Sterile swab with 70% alcohol.
6. Container with double oxalate mixture.
• Procedure:
1. Draw 2.0ml of venous blood from any convenient vein and gradually
mix it with powdered mixture of double oxalate (6 mg of
ammonium oxalate and 4 mg of potassium oxalate) in the
containers.
2. Draw the anticoagulant mixed blood into the long nozzle capillary
pipette and pass the top of the pipette right down to the bottom of
Wintrobe's tube.
3. Force the blood slowly out of the pipette by applying the pressure
on the head of the pipette. Take care and ensure that there is no air
bubble trapped in the blood.
4. Fill the tube upto zero mark and keep it vertically in the rack. Note
the time, leave it undisturbed in the position for 1 hour and read
the mm of clear plasma above the blood cells.
• Normal values:
Males- 2 to 8 mm at first hour.
Females- 4 to 10 mm first hour.
Advantages:
The sample of oxalative blood can first be used for ESR and then after 1
hour for haematocrit (PCV) by centrifuging.
Disadvantages:
This method is less sensitive because the column of the blood is not as
high as is desirable for good results and chances of error is high,
especially when the ESR is increased to over 50 mm.
• Precautions:
1. All the glass apparatus like tubes, Pipettes, dropper etc. should be
clean and absolutely dry.
2. Blood should be collected in the fasting state.
3. Once the blood has been drawn, detach the needle from the syringe
and gently transfer the blood into the bottle to prevent hemolysis.
4. Anticoagulants should be taken in a specific amount for a given
method.
5. There should be no air bubble while filling the westergren’s pipette or
Wintrobe's tube with the blood.
6. Clotted or hemolysed blood must be discarded.
7. The test should be done preferably within 2 to 3 hours after collecting
sample at room temperature of 20 to 35ᴼC.
8. Tubes should not be disturbed from vertical position.
• Physiological variations in ESR:
1. Age- ESR is low in infants (0.5 mm first hour). It gradually increases
to adult level in the next few years. However, it starts to increase
after the age of 50 years.
2. Sex- ESR is somewhat higher in females.
3. Pregnancy and menstruation- ESR begins to rise after about 3
weeks of pregnancy and return to normal after few weeks after
delivery due to hemodilution and increased fibrinogen : albumin
ratio.
4. Body temperature- within limits ESR varies with body temperature
which tends to affect viscosity.
• Pathological increase in ESR:
1. All acute and chronic infection i.e pneumonia, TB.
2. All anaemia’s except spherocytosis, sickle cell anaemia and
pernicious anaemia.
3. Bone disease- TB, osteomyelitis.
4. Connective tissue disease-SLE.
5. All malignant disease (cancer) e.g. Ca Breast, leukemia.
6. Acute non-infective inflammation- Gout.
7. Nephrosis- marked decrease in albumin level, increase fibrinogen
and globulin raise ESR.
8. Trauma, surgery- any large scale tissue injury raise ESR.
• Pathological decrease in ESR:
1. Polycythemia- high red cell counts associated with hypoxia due to
heart and lung disease such as congestive heart failure, severe
emphysema, congenital heart disease.
2. Anaemia- spherocytosis, pernicious and sickle cell anaemia.
3. Afibrinogenemia- decrease or absence of fibrinogen.
4. Severe allergic reaction.
5. Burn and dehydration- protein shock.
6. Leukemia.
Clinical significance of ESR:
1. As an indicator of bodily reaction to tissue injury and
inflammation. The ESR values are not diagnostic. Thus ESR is raised
in all organic (pathological) conditions.
2. As a prognostic tool- ESR is valuable prognostic tool in the
following- such as TB, RA etc. While a patient is on treatment, if
the weekly ESR shows a trend towards decrease, it would indicate
an improvement but if the ESR increases, it would mean that
disease is deteriorating.

Aim: To Determine Erythrocyte Sedimentation Rate (ESR)

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Aim: To determine erythrocyte

sedimentation rate (ESR).

ESR- It is the rate at which the RBC’s settle down in anti-

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