for Pedodontists

2. PHYSIOLOGY OF
BLOOD

3. CONTENTS
• Introduction
• Physical characteristics of blood
• Functions of blood
• Composition of blood
• RBC
• Leukocytes
• Platelets
• Hemostasis
• Diagnostic Tests
• Blood as a diagnostic tool
• Blood grouping
• Blood transfusion
• Literature
• Conclusion
• References

4. INTRODUCTION
• Specialized connective tissue
• Contains cells suspended in a fluid matrix
• The Only Fluid tissue in the body.
• Fluid of life
• Fluid of growth
• Fluid of health

6.  COLOR
• Normal – Red
• Abnormal – cherry red in carbon monoxide poisoning.
- Bluish discoloration due to decreased hb content.

7.  VOLUME
• Normal – Adults – 5 ltrs
- Neonates – 450 ml
• Abnormal – Hypervolemia
Hypovolemia

8.  pH
• Normal – slightly alkaline = 7.4
• Abnormal :- Metabolic Acidosis
Metabolic Alkalosis

9.  Specific gravity
• Normal :- 1.052 – 1.061 total blood
• Abnormal :- Polycythemia
Anemia

10.  viscosity
• Normal :- Five times more viscous than water
• Abnormal :- liver abnormalities (cirrhosis , alcohol damage etc)

11.  TEMPERATURE
• Normal :- Slightly higher than body temperature

12. Transportation
• Respiration
• Nutrient carrier
from GIT
• Transportation of
hormones from
endocrine glands
• Transports
metabolic wastes
FUNCTIONS OF BLOOD CLINICAL
APPLICATIONS
• Oxygen carrying
capacity of blood is
decreased in
disorders like
thalessemia(due to
altered Hb structure)
and sickle cell
anemia(due to
altered shape of
RBC)

13. Regulation
• Regulates PH
• Adjusts and
maintains body
temperature
• Maintains water
content of cells
CLINICAL
APPLICATION
• In profound shock
due to cutaneous
vasoconstriction
there is decrease in
body temperature
• Body temperature
is increased due to
vasodilatation

14. Protection
• WBC protects
against disease by
phagocytosis
• Reservoir for
substances like
water, electrolyte
etc.
• Performs
haemostasis
CLINICAL
APPLICATION
• A decrease in the
platelet count
(thrombocytopenia)
leads to impairment
in the hemostasis
mechanism.

15. COMPOSITIONOF BLOOD

16. • Water 91-92%
• Solids 8-9%
• Gases o2,co2,N
Inorganic substances
electrolytes
Organic substances
Proteins
Carbohydrates
Lipids
Non protein
nitrogenous
compounds
Hormones, Anti
bodies
enzymes
Total proteins 7.3 gm% (6.4-
8.3)
Serum albumin 4.7gm%
Serum globulin 2.3 gm%
Fibrinogen 0.3 gm%
Serum = Plasma - Fibrinogen
PLASMA

17. – Maintaining colloid osmotic balance (albumins)
– Buffering pH changes –
• Bicarbonate buffer system
• Phosphate buffer
• Protein buffer
– Reservoir of proteins
– Maintains viscocity
FUNCTIONS OF PLASMA

18. • Experimental procedure done in animals
to demonstrate the importance of plasma
proteins
• Demonstrate the synthesis of plasma
proteins by the liver
• Therapeutic plasma exchange.
• Clinical significance:
• Auto immune diseases
• Myasthenia gravis
• Thrombocytopenic purpura
PLASMAPHERESIS

19. Plasma proteins Condition when it
increases
Condition when it
decreases
Albumin Dehydration Malnutrition ,
Cirrhoses of liver ,
Burns ,
Hypothyroid disease ,
Nephrosis,
Excessive intake of water
Globulin Cirrhosis of liver,
Chronic infections ,
Nephrosis,
Rheumatoid arthritis
Emphysema ,
Acute hemolytic
anemia.
Fibrinogen Acute infections , Stroke ,
Trauma.
Liver dysfunction ,
steroids ,
use of phenol

20. RBC

21. MORPHOLOGY
• Circular, biconcave cell without a
nucleus
Normal values:
Adult male 4.5-5.5 million/
cumm
Adult female 3.8-5.2
million/cumm
At birth 4.0-6.0
million/cumm

22. ERYTHROPOIESIS
Erythropoiesis is the process by which the origin,
development and maturation of erythrocytes occur.
• 3rd week to 3rd month IU
• Mesoderm of yolksac
Mesoblastic stage
• 3rd month to 5th month IU
• Liver and spleen
Hepatic stage
• 5th month onwards
• Red bone marrow
Myeloid stage
Fetallife

23. In Post natal life and in adults
Age Site
Upto 5-6 years RBM of all bones
6-20 years RBM of long bones & all
membranous (flat) bones
After 20 years All membranous bones &
ends of long bones

24. Different stages of RBC development
Stem cell Committed
cell
Developmental pathway
Phase 1
Ribosome
synthesis
Phase 2
Hemoglobin
accumulation
Phase 3
Ejection of
nucleus
Hemocytoblast
Proerythro-
blast
Early
normoblast
intermediate
normoblast
Late
Normoblast
Reticulo-
cyte
Erythro-
cyte

25. 1. Pronormoblast : (proerythroblast)
 It is a large cell - deeply basophilic
cytoplasm with a large central
nucleus.
 The deep blue colour - high content
of RNA associated with protein
synthesis.

26. 2. Basophilic Normoblast
•This is a round cell having a diameter of
12-16 um with a large nucleus.
•The nucleus is more condensed than the
pronormoblast and contains basophilic
cytoplasm.
•This cell undergoes rapid proliferation.

27. 3. Polychromatic normoblast (Intermediate)
•The nucleus - coarse and deeply basophilic.
•The cytoplasm is polychromatic with mixture
of basophilic RNA and acidophilic hemoglobin.

28. 4. Orthochromatic (late) normoblast
•This is the final stage in the maturation
of nucleated red cells.
•The cell is smaller - small pyknotic
nucleus with dark nuclear chromatin.
•The cytoplasm - acidophilic due to large
amounts of hemoglobin.

29. 5. Reticulocytes
•Reticulocytes - devoid of nucleus
but contain RNA
•These cells in the peripheral blood
smear - slightly basophilic hue.

30. Factors influencing erythropoiesis:
1. General factors
Erythropoietin
Stem Cell Factor (SCF)
Interleukins
Colony Stimulating Factor (CSF)
Vitamin B, C, D, E
Hormones
2. Maturation factors –vit B12, folic acid – DNA synthesis
3. Factors for Hb formation - Iron and Copper
proteins, aminoacids
cobalt , nickel

31. Feed back regulationof erythropoiesis
• Regulated by renal oxygen
content.
• Erythropoietin, a glycoprotein, is
produced by renal cells in
response to a decreased renal
blood O2 content.
• Erythropoietin stimulates
erythrocyte production in the red
bone marrow.

32. Hemoglobin: (Hb )
•Forms 35 – 40% of volume of RBC
AGE NORMAL VALUE
At birth 25gm%
After 3rd month 20gm%
After 1 year 17gm%
In adult males 15gm%
In adult females 14.5gm%
•Present inside the RBC. Chromoprotein
specialized for transport of oxygen and
carbon dioxide
• Conjugated protein with mol wt
68,000 daltons

33. FUNCTIONS OF HEMOGLOBIN
1. Transport of O2
2. Transport of CO2
3. Acts as blood buffer

34. Hb Chemistry & synthesis:
•Haem ( iron & protoporphyrin )
•Globin

35. Basic Chemical Steps : (synthesis of Hb )
1. 2 succinyl-CoA + 2 glycine ------
----> pyrrole molecule
2. 4 pyrrole --------->
protoporphyrin IX
3. Protoporphyrin + ferrous iron
-------> heme
4. 2 alpha +2 beta ---------- >
globin
5. Heme + polypeptide (globin) -
--------> hemoglobin chain

36. Factors necessaryfor Hb maturation
1. Proteins and aminoacids
2. Iron
3. Copper – necessary for absorption of iron from gut
4. Cobalt and nickel for utilization of iron during Hb
formation

37. CLINICALAPPLICATIONS
• hb levels – Anemia
• hb levels – Lung diseases ( COPD, Pulmonary
fibrosis)
- Congenital heart disease
• Abnormal hb - Sickle cell Anemia
- Thalessemia

38. Life cycle of RBC

39. VARIATIONSIN NUMBEROF REDBLOODCELLS
Physiological variations
1. Increase in RBC
a) Age
b) Sex
c) High altitudes
d) Muscular exercise
e) Emotional conditions
f) Increased environmental temperature
g) After meals
2. Decrease in RBC
a) High barometric
pressures
b) After sleep
c) Pregnancy

40. Pathological Variations
1. Primary Polycythemia – Polycythemia Vera
Myeloproliferative disorders like malignancy of red
bone marrow
2. Secondary Polycythemia
a) Respiratory disorders like emphysema
b) Congenital heart disease
c) Chronic carbon monoxide poisoning
d) Poisoning by chemicals like P & As
e) Repeated mild hemorrhages

41. VARIATIONSIN SIZEOF RBC
1. Microcytes
a) Iron deficiency anemia
b) Prolonged forced breathing
c) Increased osmotic pressure in blood
2. Macrocytes
a) Megaloblastic anemia
b) Muscular exercise
c) Decreased osmotic pressure in blood
3. Anisocytes
a) Pernicious anemia

42. VARIATIONSIN SHAPEOF REDBLOODCELLS
1. Crenation
2. Spherocytosis
3. Elliptocytosis
4. Sickle cell
5. Poikilocytosis

43. VARIATIONSIN STRUCTUREOF REDBLOODCELLS
1. Punctate Basophilism:
• Dots of basophilic materials (porphyrin) appear in
RBC
• Lead poisoning
2. Ring:
• Twisted strands of basophilic materials appear in
the periphery
• Goblet ring
3. Howell – Jolly bodies:
• Nuclear fragments in the RBC

44. LEUCOCYTES

45. • Leukos = white, cytes = cells
• Mobile units of the body’s protective system.
• Colorless and nucleated formed elements of blood.
• These cells are larger in size and their number is less
compared to that of RBC’s.
Adults 4000 – 11000 cells / cumm
At birth 8000 – 28000 cells / cumm
Childhood 6000 – 15000 cells / cumm

46. properties
1) Margination
2) Diapedesis
3) chemotaxis

47. Leukocytes
Granulocytes
Neutrophils
Basophils
Eosinophils
Agranulocytes
Lymphocytes
Monocytes
CLASSIFICATIONOF LEUKOCYTES

48. Type of
leucocyte
Normal
range
Lifespan
Neutrophil 50-75 % 2-5 days
Eosinophil 1-6 % 7-12 days
Basophil 0-1% 12-15 days
Lymphocyte 25-45% ½-1
day/month
s/years
Monocyte 3-8 % 2-5 days

49. Neutrophil

50. Granules
1. Primary or azurophilic granules
2. Secondary or specific granules
3. Tertiary or gelatinase granules
4. Secretory vesicles - PAF

51. Azurophilic granules
• Myeloperoxidase, defensins, lysozyme,
azurocidin etc
• These granules fuse with phagocytes
vesicles resulting in the delivery of their
contents to the ingested organism
• Greenish coloration to pus is imparted by
myeloperoxidase

52. Secondaryor specific granules :
• 3 times more common in cytoplasm
• Lysozyme, Lactoferrin, collagenase, histaminase may
modify the inflammatory process

53. FUNCTIONS:
First line of defence
1. PHAGOCYTOSIS
2. REACTION OF INFLAMMATION
3. FEBRILE RESPONSE

54. VARIATION IN COUNTS
Neutrophilia - >1000 cumm
Physiological causes
• New born babies
• After exercise
• After meals
• Pregnancy
• Menstruation
• Parturition
• Lactation
• Mental & emotional stress

55. Pathological causes
•Acute bacterial infections
Pyogenic meningitis
Cellulitis
Infected burns
Diphtheria
•Acute inflammatory diseases like
Acute rheumatic fever
•Acute stress states like
Post surgery
Post hemorrhage
Myocardial infarction
•Chronic myeloproliferative
disorders like
Polycythemia vera

56. NEUTROPENIA:
CAUSES
• Typhoid and paratyphoid fever
• Physical agents like radiation
• Chemicals : Benzene
• Antimetabolite drugs : Cyclophosphamide, Methotrexate
• Hematologic disorders like megaloblastic anemia, aplastic
anemia, subleukemic leukemia, cyclic neutropenia

57. Variation in neutrophil morphology :
1. Variation in granules
2. Formation of vacuoles in cytoplasm
3. Formation of Dohle bodies in cytoplasm
4. Presence of sex chromatin with nuclear lobes
5. Hypersegmented neutrophils
6. Pelger – Huet anamoly

58. EOSINOPHILS :
• Forms via same stages as the neutrophil.
•Nucleus: bilobed, purple colored, spectacle shaped, nucleoli –
absent
1. Specific granules 2. Azurophilic granules
- Contain four major proteins
1. Major basic protein
2. Eosinophil cationic protein
3. Eosinophil peroxidase
4. Eosinophil derived neurotoxin
Also contains histaminase, arylsulfatase, collagenase, cathepsins

59. FUNCTIONS OF EOSINOPHILS :
1. ROLE IN PARASITIC INFESTATIONS:
• Major basic protein (MBP) : damage the parasites by
causing distension and detachment of the tegumental
sheath of these organisms.
• Eosinophil cationic protein : major destroyer of
helminths.
10 times more toxic than MBP
Destroys parasites by complete disintegration

60. • Eosinophil peroxidase : capable of destroying helminths,
bacteria and tumor cells
• Eosinophilic derived neurotoxin : destroys the nerve
fibers particularly myelinated nerve fibers.
2. ROLE IN ALLERGIC REACTION
• Capable of destroying inflammation inducing substances
like histamines and bradykinin.

61. Eosinophilia :
• Allergic conditions like hay fever,
bronchial asthma
• Parasitic infestations
• Skin diseases like urticaria
• Scarlet fever
Eosinopenia :
• ACTH & steroid therapy
• Stressful conditions
• Acute pyogenic infections

62. BASOPHILS :
• Nucleus –irregular (bi / tri lobed)
• Membrane bound granules – 0.5µ
• Chemical mediators liberated when basophils degranulate
include histamine, SRS-A
• Plays an important role in healing process
• Similar to the mast cells

63. FUNCTIONS
1. ROLE IN ALLERGIC REACTION :
release histamine, bradykinin, SRSA, serotonin.
2. ROLE IN PREVENTING SPREAD OF ALLERGIC INFLAMMATORY PROCESS
• releases eosinophil chemotactic factor
• eosinophils then phagocytose & destroy antigen – antibody complexes &
prevent spread of local inflammatory process
3. RELEASE OF HEPARIN
• Prevents clotting of the blood.
• Activates the enzyme lipoprotein lipase which removes fat
particles from the blood after a fatty meal

64. BASOPHILIA : >100 mm3
• Viral infections
• Allergic diseases
• Chronic myeloid leukemia
BASOPENIA :
• Corticosteroid therapy
• Drug-induced reactions
• Acute pyogenic infections

65. MONOCYTES
• Largest leukocytes
CFU-M
Monoblast
Promonocyte
Monocyte

66. • Nucleus : variable in appearance
ranging from indented ovoid or
roughly kidney shaped to wide horse
shoe
• Cytoplasm –
• pale grayish-blue color
• no granules
• Fine pinkish-purple granules can
also sometimes be seen
• Precursors of tissue macrophages

67. Functions
1. Phagocytosis :
second line of defense
2. Immediate precursors of macrophages
3. Releases IL-1, 6, 12, TNF-α, transferrin,
lysozyme, proteases, acid hydrolase ,PAF, CSF
4. Removes carbon particles, silicon
5. Destroys RBC in spleen

68. MONOCYTOSIS
• Parasitic conditions like malaria and kala
azar
• Infective conditions like subacute bacterial
endocarditis, tuberculosis
• Neoplastic states like acute monocytic
leukemia, acute myelomonocytic leukemia,
chronic myelomonocytic leukemia
Monocytopenia:
• Rare – bone marrow disorders

69. LYMPHOCYTES
• 20-50% of blood leukocytes
• Lack prominent cytoplasmic
granules when seen in LM.
• 10% - may contain reddish purple
staining granules
• Play an important role in immunity.

70. Committed stem cells
Pre -T cell Pre B cell
T lymphocytes B lymphocytes
Based on size
1. Small lymphocyte : 6-9µ
2. Large lymphocyte : 9-15µ

71. On the basis of functional properties
Small
lymphocytes
T-lymphocytes B-lymphocytes

72. • B- lymphocyte – humoral immunity (anti bodies)
– direct action
– making them in active by agglutination, precipitation,
neutralization or lysis
– through complement system
• T – lymphocyte – cell mediated immunity
– Cellular immune reactions – CD8
– Hypersensitivity – CD4
FUNCTIONS

73. LYMPHOCYTOSIS : >45%
• Chronic infective conditions like
tuberculosis, syphilis & brucellosis
• Viral diseases like infectious
mononucleosis, measles, chicken-
pox & viral fever
• Neoplastic conditions like CLL

74. PLATELETS

75. THROMBOCYTES :
• Greek : Thrombus : Clot; Cyte: Cell.
• Colourless, non nucleated, refractive bodies
• The number varies from 1,50,000 – 4,00,000/cumm.
• Oval or disc shaped – Inactive form
• Life span: 8 to 11 days (median value of 10 days)
• Platelets are destroyed by tissue macrophage system in
spleen

76. THROMBOCYTOPOIESIS
Stem cell Developmental pathway
Hemocyto-
blast Megakaryoblast
Promegakaryocyte
Megakaryocyte Platelets

77. • Identifiable stages are
1. Megakaryoblast
2. Promegakaryocyte
3. Megakaryocyte
4. Platelets.
• Unique feature in thrombocytopoiesis is endomitosis.
• Endomitosis : Nuclear division with cytoplasmic maturation
without cell division.
THROMBOCYTOPOIESIS

78. • As cell matures from Megakaryoblast to Megakaryocyte :
there is
• gradual increase in cell size
• Number of nuclear lobes
• Red-Pink granules
• Gradual decrease in cytoplasmic basophilia

79. Megakaryocyte
• Most abundant cells of platelet series in
marrow
• Large & contain numerous nuclear lobes with
dense nuclear chromatin, small aggregates of
granules in cytoplasm
• On maturation : Megakaryocytes extend
pseudopods through the walls of marrow
sinusoids and individual platelets break off in
to the peripheral circulation
• Thrombopoietin controls the maturation of
megakaryocytes

80. UltraStructure of platelet
• Small disk shaped fragments of granule containing cytoplasm
with diameter 2µm – 3µm.
• It posses a cell membrane – covered by fragments of
cytoplasm that are liberated from megakaryocytes.
• Small, irregular with fine cytoplasmic processes
• Cytoplasmic granules are often visible
• Central portion – granulomere (purple colored material)
• Outer region stains a transparent pale blue - hyalomere

81. OPEN CANALICULAR SYSTEM
•Tubules communicate with the platelet surface.
•This system is wide and tortuous .
•Provides a major conduit for the release of number of important
secretory substances to the exterior of the platelet.
•Peripheral zone
• cell membrane, open canalicular system, glycol proteins & receptors
•Sol-gel zone
•Microfilaments, circumferential microtubules, dense tubular system
•Organelle zone
•Alpha granules, dense granules, mitochondria, lysosomes

82. DENSE TUBULAR SYSTEM
•Lumen of the tubules consists of electron dense material and hence the
name.
•This system is narrow and is derived from the endoplasmic reticulum.
•Function is unknown.
•Has a role in sequester calcium ions that are involved in regulating the
platelet’s internal contractile activities.

83. Alpha Delta Lambda
Most numerous.
300-500 nm diameter
Less number &
Smaller size.
similar to lysosomes
Contains:
Fibrinogen
Coagulation factors
Plasminogen
PDGF,VWF& V factor
Contains
ADP,
ATP,
Serotonin and
histamine
contains
several hydrolytic
enzymes
Important role
1. initial phase of
vessel repair
2. blood coagulation &
3. platelet aggregation.
Important Role in
1. Facilitate platelet
adhesion and
2. Vasoconstriction in
the area of injured
vessel
Important Role in
1. Clot resorption in
later stages of
vessel repair.

84. FUNCTIONS
Blood clotting Responsible for formation clot by intrinsic &
extrinsic pathway through Prothrombin
activator.
Clot retraction Clot contraction & oozing of serum out is
called clot retraction.
It is by contractile proteins like myosin &
thrombosthenin in cytoplasm of platelets.
Role in repair of
ruptured blood
vessel
PDGF formed in cytoplasm of platelets is
useful for the repair of the endothelium.
Role in defense
mechanism
By agglutination property;
Platelets encircle the foreign body and destroy
through phagocytosis.

85. THROMBOCYTOPENIA
• Splenomegaly
• X-ray Radiation
• Aplastic Anemia
• Pernicious anemia
• Allergy

86. THROMBOCYTOSIS
• >4,00,000/mm3
• Leukemia
• Hodgkin’s disease
• Polycythemia Vera
• Splenectomy
• Stress
• Adrenaline injection

87. HEMOSTASIS

88. •Hemostasis refers to spontaneous arrest or prevention of
bleeding from the injured/damaged vessels by the
physiological process.
• It involves three main steps:
1. VASOCONSTRICTION
2. FORMATION OF PLATELET PLUG
3. COAGULATION OF BLOOD

89. 1. VASOCONSTRICTION
• When a vessel is severed or punctured, or when the wall of a vessel is
damaged, vascular spasm occurs.
• In vascular spasm, the smooth muscle in the walls of the vessel
contracts dramatically.
• This smooth muscle has both circular layers; larger vessels also have
longitudinal layers.

90. • The circular layers tend to constrict the flow of blood, whereas the
longitudinal layers, when present, draw the vessel back into the
surrounding tissue, often making it more difficult for a surgeon to
locate, clamp, and tie off a severed vessel.
• The vascular spasm response is believed to be triggered by several
chemicals called endothelins that are released by vessel-lining cells
and by pain receptors in response to vessel injury.
• This phenomenon typically lasts for up to 30 minutes, although it
can last for hours.

91. 2. PLATELET PLUG FORMATION
• In the second step, platelets, which normally float free in the
plasma, encounter the area of vessel rupture with the exposed
underlying connective tissue and collagenous fibers.
• The platelets begin to clump together, become spiked and
sticky, and bind to the exposed collagen and endothelial lining.
• This process is assisted by a glycoprotein in the blood plasma
called von Willebrand factor, which helps stabilize the
growing platelet plug.
• As platelets collect, they simultaneously
release chemicals from their granules into
the plasma that further contribute to
hemostasis.

92. • Among the substances released by the platelets are:
 adenosine diphosphate (ADP), which helps additional platelets to
adhere to the injury site, reinforcing and expanding the platelet
plug
 serotonin, which maintains vasoconstriction
 prostaglandins and phospholipids, which also maintain
vasoconstriction and help to activate further clotting chemicals, as
discussed next

93. • A platelet plug can temporarily seal a small opening in a blood
vessel.
• Plug formation, in essence, buys the body time while more
sophisticated and durable repairs are being made.
• In a similar manner, even modern naval warships still carry an
assortment of wooden plugs to temporarily repair small breaches
in their hulls until permanent repairs can be made.

94. 3. COAGULATION OF BLOOD
•During this process, the fibrinogen is converted
into fibrin. The fibrin threads get attached to the
loose platelet plug, which blocks the ruptured part of
blood vessels and prevents blood loss completely.

95. I FIBRINOGEN
II PROTHROMBIN
III THROMBOPLASTIN
IV CALCIUM IONS
V PROACCELERIN
VI UNKNOWN
VII PROCONVERTIN
VIII ANTIHEMOPHILIC GLOBULIN
IX CHRISTMAS FACTOR
X STUART PROWER FACTOR
XI PLASMATHROMBOPLASTIN
ANTECEDENT
XII HAGEMAN FACTOR
XIII FIBRIN STABILIZING FACTOR
HMW KININOGEN
PREKALLIKREIN
PLATELET PHOSPHOLIPID
CLOTTING FACTORS

96. 1. Formation of prothrombin activator
a) Extrinsic pathway-- initiated by tissue thromboplastin.
b) Intrinsic pathway-- initiated by factor XII
2. Conversion of prothrombin into thrombin
3. Conversion of fibrinogen into fibrin.
STAGES OF CLOTTING

98. – Lysis of blood clot inside the
blood vessel
• Plasminogen ---- Plasmin
• Plasmin digests fibrin fibres .
FIBRINOLYSIS

99. Why circulating blood does not clot?
1. Continuous movement of blood : Blood is circulated at a
constant velocity which contributes to its fluidity. That is
why, decrease in circulation velocity in some diseases is
associated with intravascular clotting.
2. Smooth endothelium lining : Smoothness of the lining
inhibits platelet adhesion
– A layer of glycocalyx on the inner lining of the
endothelium repels clotting factors and platelets.
– Intact endothelium acts as a barrier between thrombogenic
subendothelial collagen tissue and blood

100. 3. Circulatory anticoagulants : Or the so called natural
coagulants present in the blood which prevent coagulation are
– Heparin
– Antithrombin III
– Alpha 2 macroglobulin
4. Fibrinolytic mechanism
5. All the clotting factors are in inactive form
Why circulating blood does not clot?

101. ANTI-COAGULANTS
• Invivo:
– Heparin-
– Coumarin derivatives- Dicoumoral and Warfarin inhibit
action of vit k
– Genetically engineered steptokinase for treating
intravascular clots
• Invitro:
– Heparin-
– EDTA – remove calcium from blood .
– Oxalate compounds- calcium oxalate
– Citrates – Na, NH3,K citrate
ACD, CPD

102. TESTS FOR CLOTTING
1. Bleeding Time :
• Screening for – platelet disorders and Willebrand’ s disease
Normal: 3-6 minutes
• Ivy method – sphymomanometer, arm, 40 mm Hg
- 3 small punctures in forearm nearby
- Check every 3 sec, average value
- 11 min, most patients give value of 7 min
• Prolonged- purpura
quantitative & qualitative disorders of platelets
VW Disease.

103. 2. Clotting Time
• Normal : 3-8 minutes
• Prolonged: Hemophilia

104. 3. PROTHROMBIN TIME (PT)
– Time taken by blood to clot after adding tissue
thromboplastin
– PT indicates total quantity of prothrombin present in
blood.
– Normal PT : 10 - 14 sec
– Prolonged: def of prothrombin & factors I, V, VII &
X , vit K,
– Normal in hemophilia.

105. DIAGNOSTIC BLOOD TESTS

106. TESTS DETERMINES ELEVATED DEPRESSED
Hematocrit ( Hct) Percentage of formed
element in whole blood
Normal = 37 - 54
Polycythemia Anemia
Reticulocyte count Percentage of circulating
reticulocytes
Normal = 0.8%
Reticulocytosis
Hemoglobin
concentration (hb)
Concentration of hb in
blood
Normal = 12 – 14 gm/dl
Anemia
RBC Count Number of RBC’s in micro
litre of blood
Normal = 4.2 – 6.3 µl of
whole blood
Erythrocytosis /
Polycythemia
Anemia
Mean Corpuscular
Volume (MCV)
Average volume of single
RBC
Normal = 82 – 91 µm
Macrocytic Microcytic
Mean Corpuscular
Hemoglobin
concentration
Average amount of hb in
one RBC
Normal = 27 – 34 µl
Hypochromic

107. DIFFERENTIAL LEUKOCYTE COUNT
 Detects changes in WBC populations
 Infections, inflammation, and allergic reactions

108. BLOOD - AS A
DIAGNOSTIC Tool

109. 1. Infectious diseases – bacterial
- viral
- parasitic
2. Inflammatory markers – CRP
- PSR
3. Hormones – Thyroid
- Vitamin D
4. Clotting factors – Fibrinogen
- factor VIII
5. Pregnancy – Beta HC
6. Malignancy – AFP
7. Biochemical – Glucose
- Urea
- Creatinine
- Bilirubin
8. Enzymes – Serum Amylase
- Lipase
9. Electrolytes
10. Gases

110. INFECTIOUS DISEASES BLOOD TEST SUBSTANCE IDENTIFIED
HIV (AIDS) Elisa test T24 antigen and antibodies to
HIV 1 & 2
Hepatitis Elisa test Hbs Ag
Typhoid Widal test O &H antigen titre of
Salmonella typhi.
Malaria Peripheral smear Plasmodium larval forms
Sepsis CRP detection C – reactive protein
Inflammatory and
Autoimmune disorders
ESR Rate of sedimentation of
RBC’s in 1 hour

111. DISEASE BLOOD TEST SUBSTANCE IDENTIFIED
Rickets
Osteomalacia
Vitamin D Vitamin D
Hypo and Hyperthyroidism Thyroid tests T3 , t3 and TSH
Disseminated Intravscular
Coagulatiion
Clotting factors Fibrinogen and Factor VIII
Pregnancy Beta HC Released from
syncitiotrophoblasts
Malignancy
Yolk sac tumors
AFP(Alpha Feto Protein) AFP
Hypernatremia Serum Electrolytes Sodium

112. DISEASE BLOOD TEST SUBSTANCE IDENTIFIED
Diabetes Mellitus Blood Glucose Glucose levels in blood
Uremia
Chronic Kidney Disease
Urea Blood Urea
Renal Failure Serum Creatinine Creatinine
Gall stones
Liver Failure
Hepatitis
Bilirubin Bilirubin
Pancreatitis Serum Amylase
Serum Lipase
Amylase
Lipase
Hypoxia and Hypercarbia Arterial Blood gas Analysis Gases like Oxygen , Carbon
Dioxide and pH

113. BLOOD
GROUPING

114. Landsteiner -1901
• Landsteiner laws:
– If a particular antigen is present in the RBC ,
corresponding antibody must be absent in the
plasma
– If the particular antigen is absent in the RBC, the
corresponding antibody must be present in the
plasma.

116. Rh Blood Group
• Rh D — Clinically important
• Types
– Rh positive: Antigens present on surface of RBCs – 90%
– Rh negative: No antigens present on surface of RBCs –10%
• Rh antibodies not naturally occurring
• Occur when
– Rh –ve person receives Rh +ve blood
– Rh –ve mother conceives a Rh +ve fetus

117. Percentage of People Belonging
to Different Blood Groups
Population A B AB O
Europeans 42 9 3 46
Asians 25 25 5 45
Eu r op ean s
42%
9%3%
46%
A
B
AB
O
Asian s
25%
25%5%
45%
A
B
AB
O
Asian population – 85% Rh +ve and 15% Rh -ve

118. Blood Typing
Add a drop of anti-A antibodies (left) to blood
drop A
Add drop of anti-B antibodies (right) to blood
drop B

119. See If Drop A and Drop B Are Clumped By Antibodies
Type A (25%): Clumping in blood drop A with anti-A antibodies

120. Type B (25%): Clumping in blood drop B with anti-B antibodies

121. Type AB (5%): Clumping in both blood drops A and B

122. Type O (45%): No clumping in blood drops A or B

123. Add a drop of anti-Rh antibodies (anti-D serum) to a drop
of blood.
The Rh negative blood (shown above) willnot clump,
while the Rh positive blood (below) will show clumping:
Rh Neg
Blood
Rh Pos
Blood

124. ERYTHROBLASTOSIS FETALIS

125. TREATMENT
• Mother Rh -ve & Fetus Rh +ve
• Anti D  28th and 34th wk of gestation –prophylactic
measure
• Mother Rh-ve delivers Rh + ve baby, Anti D  48hrs of
delivery
• Baby born with EF  exchange transfusion

126. Patient and Donor RBC Selection by ABO
and Rh type
Patient Donor
A A, O
B B, O
AB A, B, AB, O
O O
Rh(+) Rh(+), Rh(-)
Rh(-) Rh(-)

127. Importance of blood grouping
– For blood transfusion
– In criminal practice or in forensic medicine
– In study of anthropology
– Predominance of certain diseases
– In the study of disputed paternity
– In the prevention of haemolytic disease in newborns.

128. BLOOD TRANSFUSION
• Conditions:
• Hemorrhage
• Trauma
• Burns
• anemia
• Precaution – before transfusion:
• Precaution – while transfusing
– Temperature of the blood
– Rate of blood transfusion
• 175-350 ml over 6 hrs

129. Indications For Transfusion
• WHOLE BLOOD TRANSFUSION
Loss of whole blood due to--
– Accidental injuries
– During & after major surgery
• PACKED CELL TRANSFUSION :
– Patients with severe anemia, Hb concentration < 4 gms%
• LEUKOCYTE TRANSFUSION :
– Patients with decreased immunity
– Patients suffering from agranulocytosis.

130. • PLATELET TRANSFUSION
– Disorders due to Thrombocytopenia.
• TRANSFUSION OF COAGULATION FACTORS
– Factors VIII -- hemophilic patient
– Factor IX --Christmas disease.

131. Precautions while
Blood transfusion
BEFORE
No
communicable
diseases
Matching ABO &
Rh compatibility
DURING
Volume overload
Temperature
AFTER
Observation for
delayed effects

132. Complications of Blood Transfusion
• Can be of different types:
– Transfusion reactions
– Transmission of diseases
– Reaction caused by massive transfusion
– Complication of IV fluid administration

133. • Transfusion reactions:
– Incompatibility
– Allergic reactions
– Sensitization to leukocytes & platelets
• Transmission of diseases:
– Serum hepatitis
– AIDS
– Bacterial infections

134. • Reaction due to massive transfusion :
Acid-base imbalance
Hyperkalemia
Hypothermia
• Complication of general IV fluid administration:
Thrombo embolism
Air embolism

135.  HEMODIALYSIS
• Hemodialysis is the most common type of dialysis.
• This process uses an artificial kidney (hemodialyzer) to remove waste
and extra fluid from the blood.
• The blood is removed from the body and filtered through the artificial
kidney.
• The filtered blood is then returned to the body with the help of a
dialysis machine

136. LITERATURE

137. • A term, African-American female neonate, born to a 21-yr-old
woman, was found to have jaundice at 4 hr after birth.
• The neonate’s red cells typed B, D positive, while the mother’s
red cells typed O, D negative.
• The mother’s anti-B antibody titer was 256.
• A screen for fetomaternal hemorrhage was negative.
Drabik-Clary K, Reddy VV, Benjamin WH, Boctor FN. Severe
hemolytic disease of the newborn in a group B African-American
infant delivered by a group O mother. Annals of Clinical &
Laboratory Science. 2006 Mar 20;36(2):205-7.

138. • the peripheral blood smear demonstrated numerous nucleated
RBCs, schistocytes, prominent spherocytes, polychromasia, and
mitotic figures.
• An infectious disease evaluation was negative. The patient was
diagnosed as hemolytic disease of the newborn due to ABO
incompatibility (ABO-HDN).
• The infant’s TB peaked at 16.1 mg/dl on day three, which
prompted 2 sessions of phototherapy and the transfusion of 30 ml
of red blood cells.
• Exchange transfusion was not required.
• The infant was discharged on day 8 with a TB of 3.9 mg/dl.

139. • The direct antiglobulin test (DAT) was positive with the cord
red cells, and anti-B, but not anti-A, antibody was detected
in the neonatal red cell eluate.
• The infant’s blood hemoglobin and serum total bilirubin
(TB) concentrations were 10.6 g/dl and 9.6 mg/dl,
respectively.
• Her erythrocyte glucose-6-phosphate dehydrogenase (G6PD)
activity was normal and a sickle cell test yielded negative
results.

140. AIM : To investigate the effect of RBC transfusion on iron
metabolism in critically ill patients.
METHODS
In a prospective cohort study in 61 critically ill patients who received
1 RBC unit, levels of iron variables were determined before, directly
after, and 24 hours after transfusion in septic and nonseptic patients.
The effect of red blood cell transfusion on iron metabolism in
critically ill patients
Margit Boshuizen et al.

141. RESULTS
• Serum iron levels were low and increased after transfusion (p =
0.02). However, RBC transfusion had no effect on transferrin
saturation (p = 0.14) and ferritin levels (p = 0.74).
• Hepcidin levels increased after RBC transfusion (p = 0.01), while
interleukin‐6 levels decreased (p = 0.03).
• In septic patients, RBC transfusion induced a decrease in
haptoglobin levels compared to baseline, which did not occur in
nonseptic patients (p = 0.01).
• The effect of RBC transfusion on other iron variables did not differ
between septic and nonseptic patients.

142. CONCLUSION
• Transfusion of a RBC unit transiently increases serum iron
levels in intensive care unit patients.
• The increase in hepcidin levels after transfusion can further
decrease iron release from intracellular storage making it
available for erythropoiesis.
• RBC transfusion is associated with a decrease in
haptoglobin levels in septic compared to nonseptic patients,
but did not affect other markers of hemolysis.

143. Faruk et al …
Leukocyte Counts of Typhoid Fever Patients in Kano, Nigeria
• The leukocyte counts of 73 patients with proven cases of typhoid fever
were compared with that of 80 healthy individuals and 68 non-typhoid
febrile patients in order to determine the diagnostic value of the leucocyte
counts for typhoid fever.
• The mean total white blood count (WBC) of 5.9 ± 4.3 109/l; differential
neutrophil count of 65 ± 13.3% and lymphocyte counts of 34.17 ± 13%
recorded in patients with typhoid infections were found to be significantly
different (p < 0.05) from the corresponding counts obtained in healthy
subjects.

144. • However, only the mean differential neutrophil and lymphocyte
counts of these patients were found to have significant differences (p <
0.05) from those of the patients with other febrile illnesses.
• The mean total WBC showed no statistical difference (p > 0.05).
• These findings suggest that typhoid fever in adult in Kano is
characterized by normal leukocyte count and relative neutrophilia

145. CONCLUSION

146. • Blood is essential to life.
• Blood circulates through our body and delivers essential
substances like oxygen and nutrients to the body’s cells.
• It also transports metabolic waste products away from those
same cells.
• There is no substitute for blood. It cannot be made or
manufactured.
• Generous blood donors are the only source of blood for patients
in need of a blood transfusion

147. REferences

148. • Text book of Medical Physiology- 10th edition- Guyton & Hall
• Essentials of Medical physiology-3rd edition-Sembulingam
• Per haavardsholm finne and Sverre halvorsen. Regulation of
Erythropoiesis in the Fetus and Newborn. Archives of Disease in
Childhood 1972; 47: 683-687
• M. Samoszuk. Eosinophils and human cancer. Histol Histopathol 1
997; 12: 807-81 2

149. • Simon P. Hogan et al. Eosinophils: Biological Properties and Role in
Health and Disease. Allergy and Allergic Diseases 2008; 709-750
• Robbins and Cotran Pathologic Basis of Disease – 8th edition- Vinay
kumar, Abul K Abbas
• Faruk Sarkinfada and Ado Abubakar : Leukocyte Counts Of Typhoid
Fever Ptients in Kano, Nigeria - Proceedings of The Society for
Experimental Biology and Medicine

150. • Drabik-Clary K, Reddy VV, Benjamin WH, Boctor FN. Severe
hemolytic disease of the newborn in a group B African-American
infant delivered by a group O mother. Annals of Clinical &
Laboratory Science. 2006 Mar 20;36(2):205-7.
• Margit Boshuizen et al;The effect of red blood cell transfusion on
iron metabolism in critically ill patients