Blood 1


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Blood 1

  1. 1. Good Morning
  2. 2. Dr. Nitika Jain
  3. 3.  Introduction  Properties of blood  Composition of blood  Functions of blood  Red blood cells  Erythropoiesis 4/15/2014 3BLOOD AND ITS COMPONENTS
  4. 4.  Erythrocyte sedimentation rate  White blood cells  Platelets 4/15/2014 4BLOOD AND ITS COMPONENTS
  5. 5.  Coagulation of blood  Test for clotting  Bleeding time  Clotting time  Prothrombin time  Partial Prothrombin time  Thrombin time  Bleeding disorders 4/15/2014 5BLOOD AND ITS COMPONENTS
  6. 6.  Connective tissue in fluid form  Fluid of life  Fluid of growth  Fluid of health 4/15/2014 6BLOOD AND ITS COMPONENTS
  7. 7.  Color  Volume  Reaction and pH  Specific gravity  Viscosity 4/15/2014 7BLOOD AND ITS COMPONENTS
  8. 8.  Blood cells  RBC WBC  Platelets  Plasma  Serum 4/15/2014 8BLOOD AND ITS COMPONENTS
  9. 9. 4/15/2014 9BLOOD AND ITS COMPONENTS
  10. 10.  Plasma –  Straw colored clear liquid part of the blood  Contains 91-92% water and 8-9% solids  Serum –  Clear straw colored fluid that is left after blood has been clotted.  Serum is same as plasma but only difference serum is devoid of fibrinogen ( its absent because fibrinogen is converted into fibrin during blood clotting). 4/15/2014 10BLOOD AND ITS COMPONENTS
  11. 11.  MOLECULAR WEIGHT:- Albumin:69,000 Globulin:1,56,000 Fibrinogen:4,00,000  ONCOTIC PRESSURE –  The plasma proteins are responsible for the oncotic or osmotic pressure. Normally it is about 25 mm Hg.  SPECIFIC GRAVITY-  The specific gravity plasma proteins is 1.026.  BUFFER ACTION –  Hydrogen ions is responsible for buffer action. The plasma protein have 1/6th of total buffering action of blood. 4/15/2014 11BLOOD AND ITS COMPONENTS
  12. 12.  Nutrient function  Respiratory function  Excretory function  Transport of hormones and enzymes  Regulation of water balance  Regulation of acid – base balance  Regulation of body temperature  Storage function  Defensive function 4/15/2014 12BLOOD AND ITS COMPONENTS
  13. 13.  Non – nucleated cells  Normal value  4 and 5.5 millions per cu mm of blood  Males – 5 millions/ Cu mm  Females – 4.5 millions/ Cu mm 4/15/2014 13BLOOD AND ITS COMPONENTS
  14. 14.  Morphology of RBC  Disk shaped and biconcave  Advantages of biconcave shape of RBC  Normal size  Diameter – 6.9 – 7.4µ  Thickness – Periphery – 2.2µ and centre - 1µ  Surface area – 120 sq. µ  Volume – 85 - 90 cu.µ 4/15/2014 14BLOOD AND ITS COMPONENTS
  15. 15.  Rouleaux formation  Specific gravity  1.092 to 1.101  Packed cell volume  Suspension stability  Lifespan of RBC – 120 days. After the lifetime the senile RBC are destroyed in reticuloendothelial system. 4/15/2014 15BLOOD AND ITS COMPONENTS
  16. 16.  Transport of oxygen from lungs to the tissues  Transport of CO2 from tissues to the lungs  Buffering action in blood – Hb acts as buffer  In blood group determination 4/15/2014 16BLOOD AND ITS COMPONENTS
  17. 17. 4/15/2014 17BLOOD AND ITS COMPONENTS
  18. 18.  Physiological variations  Increase in RBC count  Age  Gender  High altitude  Muscular exercise  Emotional conditions  Increased environmental temp.  After meals  Decrease in RBC count  High barometric pressure  During sleep – all the activities decreases  Pregnancy – decrease in ECF vol. – increase in plasma vol. resulting in hemodilution. 4/15/2014 18BLOOD AND ITS COMPONENTS
  19. 19. Birth – 8 to10 millions/cc Count decreases causing physiological jaundice Infants and growing children have increased count 4/15/2014 19BLOOD AND ITS COMPONENTS
  20. 20. Before puberty and menopause count is same as males During reproductive age the count is less than that of males 4/15/2014 20BLOOD AND ITS COMPONENTS
  21. 21. Temporary increase in RBC count after exercise mild hypoxia and contraction of spleen. Spleen stores RBC. Hypoxia increases the sympathetic activity resulting in secretion of adrenaline. Adrenaline contracts the spleen and hence RBC are produced 4/15/2014 21BLOOD AND ITS COMPONENTS
  22. 22. High altitude hypoxia Stimulation of kidney Production of erythrpotein Stimulation of bone marrow Production of RBC Emotional conditions Increased sympathetic activity Increased secretion of adrenaline Contraction of spleen Release of RBC 4/15/2014 22BLOOD AND ITS COMPONENTS
  23. 23.  Pathological variations  Pathological polycythemia RBC count increases 7millions/cc of blood Two types: 1.Primary 2.Secondary 4/15/2014 23BLOOD AND ITS COMPONENTS
  24. 24.  Persistent increase in RBC count above 14 millions/cc of blood.  Always associated with increased white blood cell count above 24ooo/cc of blood.  Occurs in myeloproliferative disorders like malignancy of red bone marrow 4/15/2014 24BLOOD AND ITS COMPONENTS
  25. 25.  Secondary to some of the pathological conditions:  Respiratory disorders like emphysema  Congenital heart disease  Ayerza’s disease – hypertrophy of right ventricle and obstruction of blood flow to lungs.  Chronic carbon monoxide poisoning  Poisoning by chemicals like phosphorus, and arsenic  Repeated mild hemorrahages 4/15/2014 25BLOOD AND ITS COMPONENTS
  26. 26.  Process of origin, development and maturation of erythrocytes. 4/15/2014 26BLOOD AND ITS COMPONENTS
  27. 27. 4/15/2014 27BLOOD AND ITS COMPONENTS
  28. 28.  Changes during Erythropoiesis  Reduction in size of RBC  Disappearance of nucleoli and nucleus  Appearance of hemoglobin  Change in the cytoplasm properties of the cytoplasm 4/15/2014 28BLOOD AND ITS COMPONENTS
  29. 29.  STAGES OF ERYTHROPOIESIS The various stages between stem cells and matured red blood cell are;  Proerythroblasts  Early normoblasts  Intermediate normoblasts  Late normoblasts  Reticulocytes  Matured erythrocytes 4/15/2014 29BLOOD AND ITS COMPONENTS
  30. 30. 4/15/2014 30BLOOD AND ITS COMPONENTS
  31. 31. 4/15/2014 31BLOOD AND ITS COMPONENTS
  32. 32. RBCs after 120 days Fragile Membranes of RBC rupture Phagocytized by Reticulo endothelial system Tissue macrophages  Kupffer cells  Spleen FATE OF RBC 4/15/2014 32BLOOD AND ITS COMPONENTS
  33. 33. Heme Globin Amino acid pool- reuse Free Iron Straight chain of 4 pyrole nuclei Transported in blood by transferrin Reused 4/15/2014 33BLOOD AND ITS COMPONENTS
  34. 34. Straight chain of 4 pyrole nuclei Biliverdin Free Bilirubin (released by Macrophages) Combination with plasma Albumin Blood Interstitial fluids Liver kidney-- Nil Free Bilirubin HEME OXYGENASE BILIVERDIN REDUCTASE 4/15/2014 34BLOOD AND ITS COMPONENTS
  35. 35.  The rate at which the erythrocytes settle down.  Methods:  Westergren’s method  Wintrobe’s method 4/15/2014 35BLOOD AND ITS COMPONENTS
  36. 36.  Normal values:  Westergren's method  Males – 3 to 7 mm  Females – 5 to 9 mm  Infants – 0 to 2 mm  Wintrobe’s method  Males – 0 to 9 mm  Females – 0 to 15 mm  Infants – 0 to 5 mm 4/15/2014 36BLOOD AND ITS COMPONENTS
  37. 37.  Physiological variation  Age – less in children and infants  Gender – more in females than in males  Menstruation – increases because of loss of blood  Pregnancy – from 3rd to paturition ESR increases because of hemodilution 4/15/2014 37BLOOD AND ITS COMPONENTS
  38. 38.  Pathological variation  Increased in  Tuberculosis  All types of anemia except sickle cell anemia  Malignant tumors  Rheumatoid arthritis  Rheumatic fever  Liver diseases  Decreased in  Allergic conditions  Sickle cell anemia  Polycythemia  Severe leukocytosis 4/15/2014 38BLOOD AND ITS COMPONENTS
  39. 39.  ESR is an easy, inexpensive and non specific test , which helps in diagnosis as well as in prognosis.  Certain disorders like:  Pulmonary TB  Rheumatoid arthritis  Polymyalgia rheumatica  Temporal arteritis 4/15/2014 39BLOOD AND ITS COMPONENTS
  40. 40.  Specific gravity of RBC – Increases so ESR also increases  Rouleaux formation – increases the ESR  Increase in size of RBC – increases so ESR also increases  Viscosity of blood – increases so ESR decreases  RBC count – increases so viscosity increases so ESR decreases. 4/15/2014 40BLOOD AND ITS COMPONENTS
  42. 42. 4/15/2014BLOOD AND ITS COMPONENTS 42
  43. 43.  Hb is the iron containing coloring matter of RBC  The main function of red cells is to carry O2 to the tissues and to return carbon dioxide (CO2) from tissues to the lungs.  In order to achieve this gaseous exchange the red cells contain the specialized protein haemoglobin.  Each red cell contains approximately 640 million Hb molecules. 4/15/2014BLOOD AND ITS COMPONENTS 43
  44. 44.  Average Hb in blood is 14 to 16g/dL  Age  At birth – 25g/dL  After 3rd month – 20g/dL  After 1 year – 17g/dL  From puberty onwards – 14 – 16g/dL  Gender  In adult males – 15g/dL  In adult females – 14.5g/dL 4/15/2014BLOOD AND ITS COMPONENTS 44
  45. 45.  Transport of gases  Oxygen  Oxygen + Hb known as oxygenation occurs resulting in the formation of oxyHb  Iron in this state remains as ferrous  Its an unstable compound and the combination is reversible  Carbon dioxide  Carboxyhaemoglobin is formed  Unstable and reversible  Hb has 250 times affinity for Co2 as compared to oxygen 4/15/2014BLOOD AND ITS COMPONENTS 45
  46. 46. 4/15/2014BLOOD AND ITS COMPONENTS 46
  47. 47.  IRON  In ferrous form, unstable and loose form  In some abnormal conditions gets converted into ferric form – stable form  Porphyrin  Pigment part  Formed by 4 pyrrole rings  Attached by methane bridges  Globin  4 polypeptide chains  2 alpha and 2 beta 4/15/2014BLOOD AND ITS COMPONENTS 47
  48. 48. 4/15/2014BLOOD AND ITS COMPONENTS 48
  49. 49. B B A A heme 4/15/2014 49BLOOD AND ITS COMPONENTS
  50. 50. 4/15/2014BLOOD AND ITS COMPONENTS 50
  51. 51. Hb A Hb A2 Hb F structure a2b2 a2d2 a2g2 Normal % 96-98 % 1.5-3.2 % 0.5-0.8 % 4/15/2014 51BLOOD AND ITS COMPONENTS
  52. 52.  Haem synthesis starts with the condensation of glycine and succinyl coenzyme A under the action of a rate limiting enzyme -aminolaevulinic acid synthase.  -ALA will be formed.  Pyridoxal phosphate (vit. B6) is a coenzyme for this reaction. 4/15/2014 52BLOOD AND ITS COMPONENTS
  53. 53.  A series of biochemical reactions will follow.  Two molecules of -ALA condense to form a pyrrole called porphobilinogen (PBG)  Four PBG condense to form a tetrapyrrole uroporphyrinogen III.  UPG III is then converted to coproporphyrinogen. 4/15/2014 53BLOOD AND ITS COMPONENTS
  54. 54.  CPG then changes to protoporphyrin which ultimately combines with iron in the ferrous state (Fe2+) to form haem.  Iron is brought to the developing red cells by a carrier protein ( transferrin) which attaches to special binding sites on the surface of these cells.  Transferrin releases iron and returns back to circulation. 4/15/2014 54BLOOD AND ITS COMPONENTS
  55. 55.  Each molecule of haem combines with a globin chain.  A tetramer of four globin chains each with its own haem group in a pocket is formed to make up a haemoglobin molecule. 4/15/2014 55BLOOD AND ITS COMPONENTS
  56. 56. Heme Globin Amino acid pool- reuse Free Iron Straight chain of 4 pyrole nuclei Transported in blood by transferrin Reused 4/15/2014 56BLOOD AND ITS COMPONENTS
  57. 57. Straight chain of 4 pyrole nuclei Biliverdin Free Bilirubin (released by Macrophages) Combination with plasma Albumin Blood Interstitial fluids Liver kidney-- Nil Free Bilirubin HEME OXYGENASE BILIVERDIN REDUCTASE 4/15/2014 57BLOOD AND ITS COMPONENTS
  58. 58. 584/15/2014BLOOD AND ITS COMPONENTS
  59. 59. 4/15/2014BLOOD AND ITS COMPONENTS 59
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  63. 63. 4/15/2014BLOOD AND ITS COMPONENTS 63
  64. 64. 4/15/2014BLOOD AND ITS COMPONENTS 64
  65. 65. 4/15/2014BLOOD AND ITS COMPONENTS 65
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  67. 67. 4/15/2014BLOOD AND ITS COMPONENTS 67
  68. 68. 4/15/2014BLOOD AND ITS COMPONENTS 68
  69. 69.  Hemoglobinopathies  Hemoglobin in thalassemia and related disorders 4/15/2014BLOOD AND ITS COMPONENTS 69
  70. 70.  Hemoglobin S –  Found in SC anemia  Alpha chains are normal and beta chains are abnormal  Hemoglobin C –  Beta chains are abnormal  In people with HB C diseases characterized by mild hemolytic anemia and splenomegaly  Hemoglobin E  Beta chains are abnormal  Hemoglobin M  Abnormal Hb present in the form of methHB  Occurs due to mutation  Blue baby syndrome 4/15/2014BLOOD AND ITS COMPONENTS 70
  71. 71.  HB in thalessemia and related disorders  Abnormal Hb are present  Polypeptide chains are decreased 4/15/2014BLOOD AND ITS COMPONENTS 71
  72. 72. 4/15/2014BLOOD AND ITS COMPONENTS 72
  73. 73.  Thalassemia is an inherited blood disorder that causes mild or severe anemia.  The anemia is due to reduced hemoglobin and fewer red blood cells than normal. Hemoglobin is the protein in red blood cells that carries oxygen to all parts of the body. 4/15/2014 73BLOOD AND ITS COMPONENTS
  74. 74.  In people with thalassemia, the genes that code for hemoglobin are missing or variant (different than the normal genes). Severe forms of thalassemia are usually diagnosed in early childhood and are lifelong conditions. 4/15/2014 74BLOOD AND ITS COMPONENTS
  75. 75.  Alpha and beta, are named for the two protein chains that make up normal hemoglobin.  The genes for each type of thalassemia are passed from parents to their children. Alpha and beta thalassemias have both mild and severe forms. 4/15/2014 75BLOOD AND ITS COMPONENTS
  76. 76.  Four genes are involved in making the alpha globin part of hemoglobin—two from each parent.  Alpha thalassemia occurs when one or more of these genes is variant or missing. 4/15/2014 76BLOOD AND ITS COMPONENTS
  77. 77.  People with only one gene affected are called silent carriers and have no sign of illness.  People with two genes affected (called alpha thalassemia trait, or alpha thalassemia minor) have mild anemia and are considered carriers.  People with three genes affected have moderate to severe anemia, or hemoglobin H disease.  Babies with all four genes affected (a condition called alpha thalassemia major, or hydrops fetalis) usually die before or shortly after birth. 4/15/2014 77BLOOD AND ITS COMPONENTS
  78. 78.  If two people with alpha thalassemia trait (carriers) have a child, the baby could have a mild or severe form of alpha thalassemia or could be healthy. 4/15/2014 78BLOOD AND ITS COMPONENTS
  79. 79.  Two genes are involved in making the beta globin part of hemoglobin—one from each parent. Beta thalassemia occurs when one or both of the two genes are variant. 4/15/2014 79BLOOD AND ITS COMPONENTS
  80. 80.  If one gene is affected, a person is a carrier and has mild anemia. This condition is called beta thalassemia trait, or beta thalassemia minor.  If both genes are variant, a person may have moderate anemia (beta thalassemia intermedia, or mild Cooley’s anemia) or severe anemia (beta thalassemia major, or Cooley’s anemia).  Cooley’s anemia, or beta thalassemia major, is a rare condition. A survey in 1993 found 518 Cooley’s anemia patients in the United States. Most of these persons had the severe form of the illness, but there may be more who are not diagnosed. 4/15/2014 80BLOOD AND ITS COMPONENTS
  81. 81. 1. Thalassemia is passed from parents to children through their genes. 2. Thalassemia affects both males and females. 3. Beta thalassemias affect people of Mediterranean origin or ancestry (Greek, Italian, Middle Eastern) and people of Asian and African descent. 4. Alpha thalassemias mostly affect people of Southeast Asian, Indian, Chinese, or Filipino origin or ancestry. 4/15/2014 81BLOOD AND ITS COMPONENTS
  82. 82.  The symptoms of thalassemia depend on the type and severity of the disease.  Symptoms occur when not enough oxygen gets to various parts of the body due to low hemoglobin and a shortage of red blood cells in the blood (anemia). 4/15/2014 82BLOOD AND ITS COMPONENTS
  83. 83. 1. Fatigue (feeling tired) and weakness 2. Pale skin or jaundice (yellowing of the skin) 3. Protruding abdomen, with enlarged spleen and liver 4. Dark urine 5. Abnormal facial bones and poor growth Babies with all four genes affected (a condition called alpha thalassemia major, or hydrops fetalis) usually die before or shortly after birth 4/15/2014 83BLOOD AND ITS COMPONENTS
  84. 84. 1. Thalassemia is diagnosed using blood tests, including a complete blood count (CBC) and special hemoglobin studies. 2. A CBC provides information about the amount of hemoglobin and the different kinds of blood cells, such as red blood cells, in a sample of blood. People with thalassemia have fewer red blood cells than normal and less hemoglobin than normal in their blood. Carriers of the trait may have slightly small red blood cells as their only sign. 3. Hemoglobin studies measure the types of hemoglobin in a blood sample. 4/15/2014 84BLOOD AND ITS COMPONENTS
  85. 85.  is usually diagnosed in early childhood because of signs and symptoms, including severe anemia. Some people with milder forms of thalassemia may be diagnosed after a routine blood test shows that they have anemia.  Doctors suspect thalassemia if a child has anemia and is a member of an ethnic group that is at risk for thalassemia. 4/15/2014 85BLOOD AND ITS COMPONENTS
  86. 86.  To distinguish anemia caused by iron deficiency from anemia caused by thalassemia, tests of the amount of iron in the blood may be done.  Iron-deficiency anemia occurs because the body doesn’t have enough iron for making hemoglobin.  The anemia in thalassemia occurs not because of a lack of iron, but because of a problem with either the alpha globin chain or the beta globin chain of hemoglobin. Iron supplements do nothing to improve the anemia of thalassemia, because missing iron is not the problem. 4/15/2014 86BLOOD AND ITS COMPONENTS
  87. 87.  Family genetic studies are also helpful in diagnosing thalassemia. This involves taking a family history and doing blood tests on family members.  Prenatal testing can determine if an unborn baby has thalassemia and how severe it is likely to be. 4/15/2014 87BLOOD AND ITS COMPONENTS
  88. 88. Treatment for thalassemia depends on the type and severity of the disease.  People who are carriers (they have thalassemia trait) usually have no symptoms and need no treatment. 4/15/2014 88BLOOD AND ITS COMPONENTS
  89. 89.  Those with moderate forms of thalassemia (for example, thalassemia intermedia) may need blood transfusions occasionally, such as when they are experiencing stress due to an infection.  If a person with thalassemia intermedia worsens and needs regular transfusions, he or she is no longer considered to have thalassemia intermedia; instead, the person is said to have thalassemia major, or Cooley’s anemia. 4/15/2014BLOOD AND ITS COMPONENTS 89
  90. 90. 1. Those with severe thalassemia have a serious and life-threatening illness. 2. They are treated with regular blood transfusions, iron chelation therapy, and bone marrow transplants. 3. Without treatment, children with severe thalassemia do not live beyond early childhood. 4/15/2014 90BLOOD AND ITS COMPONENTS
  91. 91.  Severe forms of thalassemia are treated by regular blood transfusions.  A blood transfusion, given through a needle in a vein, provides blood containing normal red blood cells from healthy donors. In thalassemia treatment, blood transfusions are done on a schedule (often every 2–4 weeks) to keep hemoglobin levels and red blood cell numbers at normal levels. Transfusion therapy can allow a person with severe thalassemia to feel better, enjoy normal activities, and live longer. 4/15/2014 91BLOOD AND ITS COMPONENTS
  92. 92.  Transfusion therapy, while lifesaving, is expensive and carries a risk of transmitting viral and bacterial diseases (for example, hepatitis). Transfusion also leads to excess iron in the blood (iron overload), which can damage the liver, heart, and other parts of the body. To prevent damage, iron chelation therapy is needed to remove excess iron from the body. 4/15/2014 92BLOOD AND ITS COMPONENTS
  93. 93.  Iron chelation therapy uses medicine to remove the excess iron that builds up in the body when a person has frequent blood transfusions. If the iron is not removed, it damages body organs, such as the heart and liver. 4/15/2014 93BLOOD AND ITS COMPONENTS
  94. 94.  The medicine, deferoxamine, works best when given slowly under the skin, usually with a small portable pump overnight.  This therapy is demanding and sometimes is mildly painful, so some people stop chelation therapy. A pill form of iron chelation therapy, deferasirox, was approved in November 2005 for use in the United States.  People who have iron overload should not take vitamins or other supplements that contain iron. 4/15/2014 94BLOOD AND ITS COMPONENTS
  95. 95.  Surgery may be needed if body organs, such as the spleen or gall bladder, are affected.  For example, if the spleen becomes inflamed and enlarged, it may be removed.  If gallstones develop, the gall bladder may be removed. 4/15/2014 95BLOOD AND ITS COMPONENTS
  96. 96.  Bone marrow or stem cell transplants have been used successfully in some children with severe thalassemia. This is a risky procedure, but it offers a cure for those children who qualify. 4/15/2014 96BLOOD AND ITS COMPONENTS
  97. 97.  People with severe thalassemia are more likely to get infections that can worsen their anemia. They should get an annual flu shot and the pneumonia vaccine to help prevent infections.  Folic acid is a B vitamin that helps build red blood cells. People with thalassemia should take folic acid supplements.  Researchers are also studying other treatments, such as gene therapy and fetal hemoglobin. 4/15/2014 97BLOOD AND ITS COMPONENTS
  98. 98. 4/15/2014BLOOD AND ITS COMPONENTS 98
  99. 99.  They are the measurements that describe the size and oxygen carrying protein (hemoglobin) content of red blood cells. The indices are used to help in the differential diagnosis of anemia.  The relationships between the hematocrit, the hemoglobin level, and the RBC are converted to red blood cell indices through mathematical formulas.  The indices include these measurements: mean corpuscular volume (MCV); mean corpuscular hemoglobin (MCH); and mean corpuscular hemoglobin concentration (MCHC). 4/15/2014 99BLOOD AND ITS COMPONENTS
  100. 100.  The MCV is the average volume of the RBC in cubic microns  MCV = Hct (%) X 10 / RBC count (10-12/L)  Example: Hct = 45%, RBC count = 5.0x1012/L; therefore,  MCV = 45.0x10 / 5.0 = 90fL  Cells of normal size (MCV is 80-100cu. microns) are called normocytic, smaller cells are microcytic, and larger cells are macrocytic. 4/15/2014 100BLOOD AND ITS COMPONENTS
  101. 101.  Microcytic cells are found in:  Patients with iron deficiency anemia.  Thalassemia.  Macrocytic cells are found in:  Patients with liver disease or hypothyroidism  When there is asynchrony in RBC maturation (termed megaloblastic anemia's).  Folate and vitamin B12 deficiencies. 4/15/2014 101BLOOD AND ITS COMPONENTS
  102. 102.  The MCH is the average weight of Hb in an RBC, expressed in the units of picograms (pg), or 10-12g:  MCH = Hb (g/dL) X 10 / RBC count (1012/L).  The reference range for adults is 28-32pg.  The MCH is not generally considered in the classification of anemia's.  Example:  Hb=16.0 g/fl.  RBC count=5.0x1012/l.  MCH=16.0x10 / 5.0 = 32.0pg 4/15/2014 102BLOOD AND ITS COMPONENTS
  103. 103.  The MCHC is the average concentration of Hb in each individual erythrocyte. The  units used are gram per deciliter (formerly referred to as a percentage).  MCHC = Hb (g/dL) X 100 / Hct (%).  Example: Hb =16 g /dl, Hct = 48%;  MCHC=16 X 100 / 48 = 33.3g/dL 4/15/2014 103BLOOD AND ITS COMPONENTS
  104. 104.  Values of normochromic cells range from 32 to 37g/dL.  Hypochromic cells are less than 32g/dL, and those of hyperchromic cells are greater than 37g/dL.  Hypochromic erythrocytes occur in thalassemia and iron deficiency.  Because there is a physical limit to the amount of hemoglobin that can fit in a cell, there is no hyperchromic category, a cell does not really contain more than 37g/dL of Hb, but its shape may have become spherocytic, making the cell appear full. 4/15/2014 104BLOOD AND ITS COMPONENTS
  105. 105.  Hematocrit is defined as the volume occupied by erythrocytes in a given volume of blood and is usually expressed as a percentage of the volume of the whole blood sample.  The hematocrit may also be referred to as Packed Cell Volume (PCV). 4/15/2014 105BLOOD AND ITS COMPONENTS
  106. 106.  Principle: • The hematocrit is usually determined by spinning a blood- filled capillary tube in a centrifuge.  Specimen: • Venous blood anticoagulated with EDTA or capillary blood collected directly into heparinized capillary tubes can be used. Specimens should be centrifuged within 6 hours of collection. • Hemolyzed samples cannot be used for testing. 4/15/2014 106BLOOD AND ITS COMPONENTS
  107. 107.  Reagents and equipment: • Capillary tubes, heparinized for finger sticks (red tip) or plain for anticoagulated blood (blue tip) • Clay-type tube sealant • Microhematocrit centrifuge • Microhematocrit reader • Kimwipes or gauze 4/15/2014 107BLOOD AND ITS COMPONENTS
  108. 108.  Procedure: 1. Fill two capillary tubes approximately three quarters full with blood anti-coagulated with EDTA or heparin. Alternatively, blood for heparinized capillary tubes may be collected by capillary puncture. Wipe any excess blood from the outside of the tube. 2. Seal the end of the tube with the colored ring with nonabsorbent clay 4/15/2014 108BLOOD AND ITS COMPONENTS
  109. 109. 3. Balance the tubes in the centrifuge with the clay ends facing the outside away from the center, touching the rubber gasket. 4. Tighten the head cover on the centrifuge and close the top. Activate the centrifuge for 5 minutes between 10,000 and 15,000 rpm 5. Determine the HCT by using a microhematocrit reading device Read the level of RBC packing. 6. The values of the two Hcts should agree within 2% (0.02). 4/15/2014 109BLOOD AND ITS COMPONENTS
  110. 110. Reference ranges: •Newborn 53-65% •Infant/child 30-43% •Adult male 42-52% •Adult female 37-47% 4/15/2014 110BLOOD AND ITS COMPONENTS
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  114. 114. Normocytic normochromic anemia Eg. Hemolytic anemia, anemia of chronic disease, aplastic anemia Macrocytic normochromic anemia Eg. Vitt B12 Macrocytic hypochromic anemia Eg. Protein deficiency Microcytic and hypochromic anemia Eg iron deficiency anemia 4/15/2014 114BLOOD AND ITS COMPONENTS
  115. 115. 4/15/2014 115BLOOD AND ITS COMPONENTS
  116. 116. Hemorrhagic anemia Hemolytic anemia Nutrition deficiency anemia Aplastic anemia Anemia of chronic disease 4/15/2014 116BLOOD AND ITS COMPONENTS
  117. 117.  Excessive loss of blood  Acute and chronic  Acute  Accident  Decreased RBC count causes hypoxia which stimulates the bone marrow to produce more no. of RBC.  Chronic  Internal or external bleeding over a long period of time  Like peptic ulcer, purpura, hemophilia and menorrhagia 4/15/2014 117BLOOD AND ITS COMPONENTS
  118. 118.  Excessive destruction of RBC  Two types:  Extrinsic  Liver failure  Renal disorder  Hypersplenism  Burns  Infections  Intrinsic  Generally inherited like sickle cell anemia and thalassemia 4/15/2014 118BLOOD AND ITS COMPONENTS
  119. 119.  Sickle cell anemia/ SS disease/ Sickle cell disease  inherited blood disorder  Alpha chains normal  beta chains abnormal  Mainly seen in black race and in central Africa where falciparum malaria is endemic 4/15/2014 119BLOOD AND ITS COMPONENTS
  120. 120.  Anemia – severe hemolytic anemia.  Vaso – occlusive phenomenon – recurrent vaso – occlusive due to obstruction to capillary blood flow by sickled cells upon deoxygenation or dehydration  Micro infarcts – abdomen, chest , and joints  Macro infarcts – bones, liver, kidney, spleen  Other symptoms like impaired growth and development and increased susceptibility to infection due to markedly impaired splenic function. 4/15/2014BLOOD AND ITS COMPONENTS 120
  121. 121. 4/15/2014 121BLOOD AND ITS COMPONENTS
  122. 122.  Iron deficiency anemia  Pernicious anemia/ Addison’s anemia  Megaloblastic anemia 4/15/2014 122BLOOD AND ITS COMPONENTS
  123. 123. 4/15/2014 123BLOOD AND ITS COMPONENTS
  124. 124. Country Men (%) Women (%) Pregnant Women (%) S. India 6 35 56 N. India 64 80 Latin America 4 17 38 Israel 14 29 47 Poland 22 Sweden 7 USA 1 13 4/15/2014 124BLOOD AND ITS COMPONENTS
  125. 125. Functions as electron transporter; vital for life Must be in ferrous (Fe+2) state for activity In anaerobic conditions, easy to maintain ferrous state Iron readily donates electrons to oxygen Ferric (Fe+3) ions cannot transport electrons or O2 Organisms able to limit exposure to iron had major survival advantage 4/15/2014 125BLOOD AND ITS COMPONENTS
  126. 126.  Blood Loss  Gastrointestinal Tract  Menstrual Blood Loss  Urinary Blood Loss (Rare)  Blood in Sputum (Rarer)  Increased Iron Utilization  Pregnancy  Infancy  Adolescence  Polycythemia Vera  Malabsorption  Tropical Sprue  Gastrectomy  Chronic atrophic gastritis  Dietary inadequacy (almost never sole cause)  Combinations of above 4/15/2014 126BLOOD AND ITS COMPONENTS
  127. 127. Stainable Iron, Bone Marrow Aspirate Serum Ferritin - Low in Iron Deficiency Desaturation of transferrin Serum Iron drops Transferrin (Iron Binding Capacity) Increases Blood Smear - Microcytic, Hypochromic; Aniso- & Poikilocytosis Anemia 4/15/2014 127BLOOD AND ITS COMPONENTS
  128. 128.  Fatigue - Sometimes out of proportion to anemia  Atrophic glossitis  Pica  Koilonychia (Nail spooning)  Esophageal Web 4/15/2014 128BLOOD AND ITS COMPONENTS
  129. 129. Correction of the disorder Correction of iron deficiency  Oral therapy  Ferrous sulphate – 6omg TID  Ferrous gluconate – 37mg  Parenteral therapy  Dose is calculated by multiplying the grams of Hb below normal with 250.  Given as single IM iron dextran(interferon)  Repeated inj. Of iron sorbitol citrate (jectofer) 4/15/2014 129BLOOD AND ITS COMPONENTS
  130. 130. Dietary modification Food fortification Iron supplementation 4/15/2014 130BLOOD AND ITS COMPONENTS
  131. 131. Diet & nutrition education eat more fruits and vegetable no coffee or tea with meals programmes should be targeted to at risk groups reduce phytic content of cereals and legumes by fermentation 4/15/2014 131BLOOD AND ITS COMPONENTS
  132. 132.  Short term approach:  supplementation with iron tablets.  Long-term approach:  food fortification with iron either for the whole population (blanket fortification) or for specific target groups like infants. It requires no cooperation from users unlike taking iron supplements. 4/15/2014 132BLOOD AND ITS COMPONENTS
  133. 133.  Iron compounds used in food fortification can be divided into 4 groups Freely water soluble (ferrous sulphate, gluconate, lactate & ferric ammonium citrate). Poorly water soluble (ferrous fumarate, succinate & saccharate). Water insoluble (ferric pyrophosphate, ferric orthophosphate & elemental iron). 4/15/2014 133BLOOD AND ITS COMPONENTS
  134. 134.  The major factors governing the choice of iron compound include: Bioavailability Organoleptic problems Cost Safety  Ideally we should go for a safe, cheap, highly bioavailable iron, which causes no organoleptic side-effects 4/15/2014 134BLOOD AND ITS COMPONENTS
  135. 135.  Freely water soluble iron are the most bio-available, but causes unacceptable colour & flavour change in many foods.  Insoluble iron compounds are inert with no organoleptic effects but it is poorly absorbed  Cost-wise elemental iron is the cheapest, ferrous sulphate costs 10 times more, but most expensive is EDTA  Safety is of concern with EDTA & Bovine Hb only because of potential problems 4/15/2014 135BLOOD AND ITS COMPONENTS
  136. 136. 4/15/2014BLOOD AND ITS COMPONENTS 136
  137. 137. 137 1. Vit. B12 deficiency 2. Folic acid deficiency 3. Other causes like drugs which interfere with DNA synthesis, acquired defects of hemopoietic stem cells and congenital enzyme deficiency. 4/15/2014BLOOD AND ITS COMPONENTS
  138. 138. 138 Vitamin B12 Folic acid Sources meat, fish green vegetables, yeast Daily requirement 2-5 ug 50-100 ug Body stores 3-5 mg (liver) 10-12mg (liver) Places of absorption ileum duodenum and proxymal segment of small intestine 4/15/2014BLOOD AND ITS COMPONENTS
  139. 139. 4/15/2014BLOOD AND ITS COMPONENTS 139
  140. 140.  First described by Addison in 1855 as a chronic disorder of middle aged and elderly individual of either sex in which intrinsic factor secretion ceases owing to atrophy of the gastric mucosa.  Average age is 60yrs.  Bur rarely can be seen in children ( juvenile pernicious anemia)  Mostly seen in northern European descent and American blacks and is uncommon in South European. 4/15/2014BLOOD AND ITS COMPONENTS 140
  141. 141.  Insidious onset and progress slowly  Mainly due to Vit. B12 deficiency  Anemia, Glossitis, Neurological abnormalities ( neuropathy, subacute combined degeneration of the spinal cord, retrobulbar neuritis) GIT manifestation ( diarrhoea, anorexia, weight loss, dyspepsia), hepatospleenomegaly, congestive heart failure and hemorrhagic manifestation 4/15/2014BLOOD AND ITS COMPONENTS 141
  142. 142.  Hypergastrinaemia  Pentagastrinaemia  Haematologic findings -  Rise in serum bilirubin, LDH, haptoglobin, ferrritin and iron.  Chromosomal abnormalities are frequently present in bone marrow cells which disappear after therapy. 4/15/2014BLOOD AND ITS COMPONENTS 142
  143. 143.  Replacement therapy with vitamin B12  Vitamin B12 administration intramuscular in dose 1000 (100) μg per day for a week , then 100 μg 2x per week for 2 weeks, 1 x per week 100μg for month  Reticulocytosis begins 2 or 3 days after therapy started and maximal number reached on day 5 to 8.  Serum iron monitoring, after 7-10 days of vit.B12 treatment,  If Fe deficiency is diagnosed we should start iron substitution  100 ug vit.B12 i.m. every month, regimen that must be maintained for the rest on the patients life.  Physiotherapy for neurologic deficits and occasionally blood transfusion  Follow up early detection of cancer of the stomach 4/15/2014BLOOD AND ITS COMPONENTS 143
  144. 144. 4/15/2014BLOOD AND ITS COMPONENTS 144
  145. 145. 145 1. Inadequate intake - diet lacking fresh, slightly cook food; chronic alcoholism, total parenteral nutrition, 2. Malabsorption - small bowel disease (sprue, celiac disease,) - alcoholism 3. Increased requirements: - pregnancy and lactation - infancy - chronic hemolysis - malignancy - hemodialysis 4. Defective utilisation Drugs:folate antagonists(methotrexate, trimethoprim, triamteren), purine analogs (azathioprine), primidine analogs (zidovudine), RNA reductase inhibitor (hydroxyurea), miscellaneous (phenytoin, N2) 4/15/2014BLOOD AND ITS COMPONENTS
  146. 146. 146 1. Symptoms of anemia 2. Symptoms associated with vit. B12 or Folic acid deficiency neurologic manifestations (exclusivly in wit. B12 deficiency) - megaloblastic madness or psychosis, - subacute, combined degeneration of the spinal cord (proprioceptive and vibratory sensation, spinal ataxia) gastrointestinal compraints (vit.B12 and folic acid deficiency) - loss of appetite - glosstis (red, sore, smooth tongue) - diarrhea or constipation 4/15/2014BLOOD AND ITS COMPONENTS
  147. 147. 147 1. Blood cell count: macrocytic anemia thrombocytopenia leucopenia (granulocytopenia) low reticulocyte count 2. Blood smear: hypersegmentation of granulocytes macroovalocytes , anisocytosis, poikilocytosis 4/15/2014BLOOD AND ITS COMPONENTS
  148. 148. 148 3. Laboratory features indirect hyperbilirubinemia elevation of lactate dehrogenase (LDH) serum iron concentration- normal or increased 4. Bone marrow smear hypercellular increased erythroid /myeloid ratio erythroid cell changes (megaloblasts, RBC precursor a abnormally large with nuclear- cytoplasmic asynchrony) myeloid cell changes (giant bands and metamyelocytes , hypertsegmentation) megakariocytes are decreased and show abnormal morphology 4/15/2014BLOOD AND ITS COMPONENTS
  149. 149. 149 1. Establishing megaloblastic anemia 2. History: causes of folate deficiency 3. Absence neurologic symptoms 4. Low serum and red blood cell folic acid 4/15/2014BLOOD AND ITS COMPONENTS
  150. 150. 150 FOLIC ACID DEFICIENCY ANEMIA 1. Oral administration of Ac. folicum 1 (5) mg per day, for 3 months, and maintenance therapy if it’s necessary. 2. Reticulocytosis after 5-7 days 3. Correction of anemia is over after 1-2 months therapy 4. Maintenance therapy if necessary 4/15/2014BLOOD AND ITS COMPONENTS