Erythrocyte Sedimentation Rate (ESR): Automated Analysis
The erythrocyte sedimentation rate (ESR), or the sed rate, is a simple, nonspecific marker of underlying
inflammation. It is often used to screen patients with fevers of undetermined origin, arthritides, muscle
pains, and other vague symptoms. ESR testing is specifically indicated for certain conditions: to monitor
rheumatoid arthritis, tuberculosis, and systemic lupus erythematosis; and to diagnose and monitor giant
cell arteritis and polymyalgia rheumatica. An elevated ESR may also be associated with many other
conditions, including other autoimmune disease, anemia, infection, and malignancy.
Zoom In
ESR testing has long been used in the clinical setting. Measurement of the erythrocyte sedimentation
rate was first described in 1897 by the Polish physician, Edmund Biernacki. In 1918, the method was
refined by the Swedish pathologist Robert Sanno Fåhræus and the internist Alf Vilhelm Albertsson
Westergren. Years later, the cornerstone ESR testing method is still referred to as the Westergren
method, and it is the recommended ESR testing method of the International Committee for
Standardization in Hematology. The reference ranges for the Westergren ESR are based on age and sex.
Westergren Method
For the Westergren method, whole blood is mixed with sodium citrate and then added to a standardized
calibrated tube, which is allowed to sit for 60 min. After 60 min, sedimentation is measured by recording
the number of millimeters between the top of the sedimented red blood cells and the zero mark at the
top of the tube. The modified Westergren method uses EDTA as the anticoagulant instead of sodium
citrate. For both procedures, the results are expressed as millimeters per hour (mm/hr).
While the Westergren method is a simple test to perform manually, minor technical problems can cause
erroneous test results. Common errors include dilution caused by liquid anticoagulant (sodium citrate
solution), mixing errors, and handling errors such as tilted tubes and vibrations occurring during the
sedimentation period.
Automated Analysis
Today, there are automated ESR systems that provide faster results and address laboratory safety by
minimizing contact with blood samples.
Automated Systems Based on the Westergren Method
Streck, Inc. (Omaha, NE) offers the CE-marked Streck ESR-Auto Plus®, a 10-position automated benchtop
ESR analyzer. This instrument uses infrared light that accurately measures the sedimentation rate of
erythrocytes in 1.2-mL ESR-Vacuum Tubes that are supplied separately. The vacuum tubes allow direct-
draw collection and can be ordered with a Mylar safety coating which provides impact resistance and
will contain glass and blood specimens in the event of breakage. Results are measured in mm/hr
(modified Westergren method) and are available in 30 min; therefore, the analyzer can handle 20
samples/hr. The company reports >98% correlation with the manual modified Westergren method. The
instrument features random access, a built-in printer, sample ID capability, and a 15-minute prediction
mode. The ESR-Auto Plus incorporates a quality control system for monitoring the laboratory's quality
control program and data can be downloaded to a laboratory information system. This quality control
feature of the ESR-Auto Plus eliminates the need to manually record daily runs. Control samples are
stored in individual log files that hold up to 100 samples per level. Statistical reports are generated with
the following features: standard deviation, percent coefficient of variation, mean, and highest and
lowest result.
Mechatronics USA LLC (East Providence, RI) offers the StaRRsed Compact, a benchtop automated ESR
analyzer. It provides a standard Westergren result and conforms to the recommendations of the
International Council for Standardization in Haematology. It has a built-in barcode reader and provides
full walk-away operation for 30 samples (1.6 mL). The instrument uses existing blood-cell counter racks,
and results are available in 30 or 60 min, with continuous throughput. Each machine is equipped with 84
high-precision-bore glass Westergren pipets that can be reused, and each analysis is temperature
corrected to 18.3 ºC. There is a citrate diluter system, so that a sample can be taken from an EDTA blood
collection tube, which is manually loaded. Hazy samples can be detected by an optical reader.
Automated System Using an Alternative Method
HemaTechnologies (Lebanon, NJ) offers the ESR STAT™ PLUS analyzer, a second-generation automated
sed rate analyzer that uses EZ-SAFE™ Mylar-wrapped, self-sealing analysis tubes. The ESR STAT PLUS
provides sed rates in 5 min from three 25-μL samples. The blood is taken from EDTA blood collection
tubes. It has a direct-read feature, but can be used with a barcode reader/printer. The company reports
0.96% correlation with the Westergren method. The ESR STAT PLUS employs centrifugation at 1500 to
2000 rpm for 3 min, and an infrared laser tracks the erythrocyte–plasma interface and makes multiple
measurements, from which the linear portion of the sedimentation curve is identified and used by the
software algorithm to determine the ESR result (mm/hr).
Choosing an Automated ESR System
Automated erythrocyte sedimentation rate analyzers improve workflow, turnaround time, and
laboratory safety. Automated ESR analyzers also allow for uncomplicated sed rate determination and
quality control. Depending on your laboratory's requirements, key considerations include capacity,
analysis time, throughput, and dimensions.
