Blood 2


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Blood 2

  1. 1. 333
  2. 2. The blood group system 4/15/2014 2BLOOD AND ITS COMPONENTS
  3. 3. History of Blood Groups and Blood Transfusions •Experiments with blood transfusions have been carried out for hundreds of years. Many patients have died and it was not until 1901, when the Austrian Karl Landsteiner discovered human blood groups, that blood transfusions became safer. • He found that mixing blood from two individuals can lead to blood clumping. The clumped RBCs can crack and cause toxic reactions. This can be fatal. 4/15/2014 3BLOOD AND ITS COMPONENTS
  4. 4. • Karl Landsteiner discovered that blood clumping was an immunological reaction which occurs when the receiver of a blood transfusion has antibodies against the donor blood cells. •Karl Landsteiner's work made it possible to determine blood types and thus paved the way for blood transfusions to be carried out safely. For this discovery he was awarded the Nobel Prize in Physiology or Medicine in 1930. History of Blood Groups and Blood Transfusions (Cont.) 4/15/2014 4BLOOD AND ITS COMPONENTS
  5. 5. • There are more than 20 genetically determined blood group systems known today • The AB0 and Rhesus (Rh) systems are the most important ones used for blood transfusions. • Not all blood groups are compatible with each other. Mixing incompatible blood groups leads to blood clumping or agglutination, which is dangerous for individuals. What are the different blood groups? 4/15/2014 6BLOOD AND ITS COMPONENTS
  6. 6. According to the ABO blood typing system there are four different kinds of blood types: A, B, AB or O (null). ABO blood grouping system 4/15/2014 7BLOOD AND ITS COMPONENTS
  7. 7. Blood Types 4/15/2014 8BLOOD AND ITS COMPONENTS
  8. 8. 4/15/2014 9BLOOD AND ITS COMPONENTS
  9. 9. Blood group A the blood group A, means A antigens on the surface of your RBCs and B antibodies in blood plasma. Blood group B the blood group B, means B antigens on the surface of RBCs and A antibodies in blood plasma. AB0 blood grouping system 4/15/2014 10BLOOD AND ITS COMPONENTS
  10. 10. Blood group AB the blood group AB, means both A and B antigens on the surface of RBCs and no A or B antibodies at all in blood plasma. Blood group O the blood group O (null), means neither A or B antigens on the surface of your RBCs but have both A and B antibodies in blood plasma. 4/15/2014 11BLOOD AND ITS COMPONENTS
  11. 11. • The ABO gene is autosomal (the gene is not on either sex chromosomes) • The ABO gene locus is located on the chromosome 9. • Each person has two copies of genes coding for their ABO blood group (one maternal and one paternal in origin) • A and B blood groups are dominant over the O blood group • A and B group genes are co-dominant ABO inheritance and genetics 4/15/2014 12BLOOD AND ITS COMPONENTS
  12. 12. This meant that if a person inherited one A group gene and one B group gene their red cells would possess both the A and B blood group antigens. These alleles were termed A ( which produced the A antigen ), B (which produced the B antigen) and O (which was non functional and produced no A or B antigen) What do co-dominant genes mean? 4/15/2014 13BLOOD AND ITS COMPONENTS
  13. 13. Parent Allele A B O A B O Possible Blood group Genotypes 4/15/2014 14BLOOD AND ITS COMPONENTS
  14. 14. Parent Allele A B O A AA AB AO B AB BB BO O AO BO OO Possible Blood group Genotypes 4/15/2014 15BLOOD AND ITS COMPONENTS
  15. 15. The ABO blood groups • The most important in assuring a safe blood transfusion. •The table shows the four ABO phenotypes ("blood groups") present in the human population and the genotypes that give rise to them. Blood Group Antigens on RBCs Antibodies in Serum Genotypes A A Anti-B AA or AO B B Anti-A BB or BO AB A and B Neither AB O Neither Anti-A and anti-B OO4/15/2014 16BLOOD AND ITS COMPONENTS
  16. 16. Why group A blood must never be given to a group B person? Giving someone blood from the wrong ABO group could be fatal. The anti-A antibodies in group B attack group A cells and vice versa. 4/15/2014 17BLOOD AND ITS COMPONENTS
  17. 17. more complicated, because there's another antigen to be considered - the Rh antigen. If it is present, the blood is RhD positive, if not it's RhD negative. So, for example, some people in group A will have it, and will therefore be classed as A+ (or A positive). While the ones that don't, are A- (or A negative). And so it goes for groups B, AB and O. The Rhesus (Rh) System 4/15/2014 18BLOOD AND ITS COMPONENTS
  18. 18. • Rh antigens are transmembrane proteins with loops exposed at the surface of red blood cells. • They appear to be used for the transport of carbon dioxide and/or ammonia across the plasma membrane. • They are named for the rhesus monkey in which they were first discovered. • RBCs that are "Rh positive" express the antigen designated D. • 85% of the population is RhD positive, the other 15% of the population is running around with RhD negative blood. The Rhesus (Rh) System (Cont.) 4/15/2014 19BLOOD AND ITS COMPONENTS
  19. 19. Blood Type Genotype Alleles Produced Rh positive RR R Rr R or r Rh negative rr r Rh Blood Group and Rh Incompatibility A person with Rh- blood does not have Rh antibodies naturally in the blood plasma 4/15/2014 20BLOOD AND ITS COMPONENTS
  20. 20. Why is an Rh incompatibility so dangerous when ABO incompatibility is not during pregnancy? • Most anti-A or anti-B antibodies are of the IgM class (large molecules) and these do not cross the placenta. •In fact, an Rh−/type O mother carrying an Rh+/type A, B, or AB foetus is resistant to sensitisation to the Rh antigen. •Her anti-A and anti-B antibodies destroy any foetal cells that enter her blood before they can elicit anti- Rh antibodies in her. 4/15/2014 21BLOOD AND ITS COMPONENTS
  21. 21. •This phenomenon has led to an effective preventive measure to avoid Rh sensitisation. •Shortly after each birth of an Rh+ baby, the mother is given an injection of anti-Rh antibodies (or Rhogam). •These passively acquired antibodies destroy any foetal cells that got into her circulation before they can elicit an active immune response in her. Rh incompatibility during pregnancy (cont.) 4/15/2014 22BLOOD AND ITS COMPONENTS
  22. 22. People with blood group O are called "universal donors" and people with blood group AB are called "universal receivers." Blood transfusions – who can receive blood from whom? 4/15/2014 23BLOOD AND ITS COMPONENTS
  23. 23. Blood Group Antigens Antibodies Can give blood to Can receive blood from AB A B O 4/15/2014 24BLOOD AND ITS COMPONENTS
  24. 24. Blood Group Antigens Antibodies Can give blood to Can receive blood from AB A and B None AB AB, A, B, O A A B A and AB A and O B B A B and AB B and O O None A and B AB, A, B, O O 4/15/2014 25BLOOD AND ITS COMPONENTS
  25. 25. Complications of blood transfusion 4/15/2014 BLOOD AND ITS COMPONENTS 26
  26. 26. Non immunological transfusion reaction 1. Bacterial contamination reactions. 2. Circulatory overload. 3. Transfusion haemosiderosis. 4. Complications of massive transfusion. 5. Non immune hemolytic reaction 6. Disease transmission. 4/15/2014 27BLOOD AND ITS COMPONENTS
  27. 27. 1. Bacterial contamination reaction. • Although uncommon,but this type of specific reaction can have a rapid onset and high mortality in recipients. • The presence of bacteria in transfused blood may lead either to febrile reactions in the recipient ( due to pyrogens ) or serious manifestations of septic or endotoxic shock. • Commonly caused by endotoxin produced by bacteria capable of growing in cold temperatures such as Pseudomonas species, E. coli, Yersinia enterocolitica. 4/15/2014 28BLOOD AND ITS COMPONENTS
  28. 28. Source of infection. • Infection of stored blood is extremely rare. • Skin contaminants are not infrequently present in freshly donated blood but these organisms ( predominantly staphylococci ) do not survive storage at 4 º C although they will grow profusely in platelet concentrates stored at 22 º C. • Healthy donor who are bacteremic at the time of donation. The majority are due to Yersinia enterocolitica, which grows well in red cell components due to its dependence on citrate and Iron. • Gram negative, endotoxin – producing contaminants found in dirt, soil and faeces may rarely grow in the storage condition of blood. 4/15/2014 29BLOOD AND ITS COMPONENTS
  29. 29. •According to CDC , most are caused by blood components contaminated by Yersinia enterocolitica. •Since 1987, from 20 cases reported to CDC, 12 are caused by this organism. 4/15/2014 30BLOOD AND ITS COMPONENTS
  30. 30. Clinical manifestation • Usually appear rapidly during transfusion or within about 30 minutes after transfusion with dryness, flushing of skin. • Fever, Hypotension, Chills, Muscle pain, vomiting, Abdominal cramps, Bloody diarrhoea, Hemoglobinuria, Shock, Renal failure, DIC. 4/15/2014 31BLOOD AND ITS COMPONENTS
  31. 31. Management. • Rapid recognition is essential • Immediately stop the transfusion. • Therapy of shock, steroids, vassopressors, fluid support, respiratory ventilation and maintenance of renal function. • Broad spectrum IV antibiotics • The blood component unit and any associated fluids and transfusion equipment should be sent immediately to blood bank for investigation ie: gram stain and culture. 4/15/2014 32BLOOD AND ITS COMPONENTS
  32. 32. Prevention • Strict adherence to policies & procedures regarding blood component collection, storage, handling,and preparation is essential to reduce the risk. • Visual Inspection of components before release from the transfusion service include any discolouration, visible clots, or hemolysis. • Ensure the blood components are infused within standard time limits ( 4 hours ). 4/15/2014 33BLOOD AND ITS COMPONENTS
  33. 33. Prevention • Blood packs should never be opened for sampling, if any open method of preparation has been used, the unit should be transfused within 24 hours. • Blood should always be kept in accurately controlled refrigerators (with alarms), maintained strictly at 2 – 6 º C, the blood should never be removed and taken to the ward or OT until it is recquired. 4/15/2014 34BLOOD AND ITS COMPONENTS
  34. 34. 2. Circulatory overload • All patient will experience a temporary rise in blood volume and venous pressure following the transfusion of blood or plasma except for those who are actively bleeding. However, young people with normal cardiovascular function will tolerate this changes provided it is not excessive. • Pregnant women, patient with severe anaemia, elderly with compromised cardiovascular function will not tolerate the increase in plasma volume and acute pulmonary oedema may develop. 4/15/2014 35BLOOD AND ITS COMPONENTS
  35. 35. Clinical manifestation • Frequently due to transfusion of a unit at too fast rate. • Signs of cardiac failure – raised JVP, basal crepitations in both lungs, dry cough, breathlessness. 4/15/2014 36BLOOD AND ITS COMPONENTS
  36. 36. Management • Stop the transfusion immediately. • Prop up the patient • Oxygen therapy • Intravenous diuretics should be used appropriately. 4/15/2014 37BLOOD AND ITS COMPONENTS
  37. 37. Prevention • Packed cell should be used instead of whole blood. • Packed cells should be given slowly over 4 hours.The usual rate of transfusion is about 200 ml per hour. In patient at risk rate of 100 ml per hour or less are appropriate. • Diuretics should be given at the start of the transfusion and only one or two units of concentrated red cells should be transfused in any 24 hour period. • Blood transfusion should be given during the daytime, Overnight transfusion should be avoided wherever possible. 4/15/2014 38BLOOD AND ITS COMPONENTS
  38. 38. 3. Transfusion haemosiderosis • A complication of repeated long term blood transfusion. • Most commonly seen in thalassaemic patient. • Each unit of blood has about 200 mg of iron, while the daily excretion rate is about 1 mg. The body has no way of excreting the excess unless the patient is bleeding. • Assessment of storage iron levels such as ferritin levels should be done. 4/15/2014 39BLOOD AND ITS COMPONENTS
  39. 39. The use of Iron chelating agent, Desferrioxamine does not completely overcome the Iron load, but has delayed the onset of problems due to haemosiderosis. Transfusion of neocytes or young red cells is the other alternative. However, it is expensive, time consuming, and the result are not as favourable as expected. 4/15/2014 40BLOOD AND ITS COMPONENTS
  40. 40. 4. Complication of massive transfusion • Massive transfusion is defined as the replacement of total blood volume within a 24 hour period. • This will inevitably lead to : 1. Dilution of platelets. Blood effectively has no functional platelets after 48 hours storage, after 8 to 10 units of blood transfusion, thrombocytopenia will usually seen. Bleeding due to a slightly low platelet is uncommon, therefore routine administration of platelet after certain amount of blood transfusion is unnecessary. Regular monitoring of platelet count is more important. Platelet transfusion may be recquired if platelet count <100 x 10 9 /L with continous bleeding or surgical intervention. 4/15/2014 41BLOOD AND ITS COMPONENTS
  41. 41. 2. Dilution of coagulation factors. Stored Whole blood < 14 days has adequate levels of most coagulation factors for haemostasis. If stored blood of more than 14 days, or plasma reduced blood or red cells in optimal additive solution is used, replacement of coagulation factors with FFP is necessary. 3. Hypothermia ( defined as core body temperature less than 35 c ) is associated with large volumes of cold fluid transfusion. This may results in cardiac irregularities in particular VF. Therefore the use of blood warmer is important. 4/15/2014 42BLOOD AND ITS COMPONENTS
  42. 42. 4. Excess citrate can act on the patient’s plasma free ionized calsium and results in hypocalcaemia (transient ).Citrate toxicity occur with extremely rapid transfusion ( one unit every 5 minute ), in premature infant having ET with blood stored in citrate for longer than 5 days. 5. Hyperkalemia Can be caused by intracellular loss of potassium from RBC during storage or infusion of intracellular potassium depleted RBC blood components such as washed RBC or frozen washed RBC . 4/15/2014 43BLOOD AND ITS COMPONENTS
  43. 43. The most important consideration in massive blood transfusion is to replace blood loss quickly and adequately. Too little blood , too late has more serious consequences than massive blood transfusion itself. 4/15/2014 44BLOOD AND ITS COMPONENTS
  44. 44. 5.Non immune hemolytic reaction • Mechanical – heat damage from blood warmer, cold, small gauge needle. • Environment – hypotonic or hypertonic solution. 4/15/2014 45BLOOD AND ITS COMPONENTS
  45. 45. 6. Disease transmission. • Hepatitis • Syphilis • Malaria • Cytomegalovirus • Human immunodeficiency virus • Human T cell leukaemia viruses. Donor selection criteria and subsequent screening of all donations are designed to prevent disease transmission, but these do not completely eliminate the hazards. 4/15/2014 46BLOOD AND ITS COMPONENTS
  46. 46. White blood cells • Different from RBC – Larger in size – Irregular in shape – Nucleated – Many types – Granules are present in some type of WBC – Life span is shorter 4/15/2014 47BLOOD AND ITS COMPONENTS
  47. 47. 4/15/2014 BLOOD AND ITS COMPONENTS 48
  48. 48. Classification Of wbc WBC Granulocytes Neutrophils Eosinophils Basophils Agranulocytes Monocytes Lymphocytes 4/15/2014 49BLOOD AND ITS COMPONENTS
  49. 49. 4/15/2014 BLOOD AND ITS COMPONENTS 50
  50. 50. Neutrophils • Neutrophil – 2-5 lobe nucleus – Primary granules • Pink (azurophilic granules) stained by Azure stain • Grey-blue granules • Contain elastase, cathepsin G, myeloperoxidase – Secondary granules • Specific granules • Contain lactoferrin – Tertiary granules • Gelatinase, cathepsin – Life 10 hours – Diameter – 10 to µM 4/15/2014 51BLOOD AND ITS COMPONENTS
  51. 51. 4/15/2014 BLOOD AND ITS COMPONENTS 52
  52. 52. Eosinophils • Coarse granules in the cytoplasm, which stain pink or red with eosin • Bilobed nucleus • Diameter - 10 to 14 µM 4/15/2014 53BLOOD AND ITS COMPONENTS
  53. 53. Basophils • Coarse cytoplasm in the cytoplasm • Stain purple blue with methylene blue • Bilobed nucleus • Diameter - 8 to 10 µM 4/15/2014 54BLOOD AND ITS COMPONENTS
  54. 54. 4/15/2014 BLOOD AND ITS COMPONENTS 55
  55. 55. Monocytes • Largest leukocytes with diameter of 14 to 18 µM • Cytoplasm is clear without any granules • Nucleus is round, oval horse shoe shaped, bean shaped or kidney shaped 4/15/2014 56BLOOD AND ITS COMPONENTS
  56. 56. 4/15/2014 BLOOD AND ITS COMPONENTS 57
  57. 57. Normal count 4/15/2014 58BLOOD AND ITS COMPONENTS
  58. 58. lymphocytes • No granules • Two groups based on size: – Large – diameter – 10 to 12mm – Small – diameter – 7 to 10mm • Two groups based on function – T – lymphocytes – B - lymphocytes 4/15/2014 59BLOOD AND ITS COMPONENTS
  59. 59. • B – LYMPHOCYTES – B cells make antibodies that bind to pathogens to enable their destruction. (B cells not only make antibodies that bind to pathogens, but after an attack, some B cells will retain the ability to produce an antibody to serve as a 'memory' system.) 4/15/2014 60BLOOD AND ITS COMPONENTS
  60. 60. • T – LYMPHOCYTES – CD4+ (helper) T cells co-ordinate the immune response and are important in the defence against intracellular bacteria. – CD8+ cytotoxic T cells are able to kill virus-infected and tumor cells. • Natural killer cells: Natural killer cells are able to kill cells of the body which are displaying a signal to kill them, as they have been infected by a virus or have become cancerous 4/15/2014 61BLOOD AND ITS COMPONENTS
  61. 61. platelets • Small colorless, non – nucleated, and moderately refractive bodies 4/15/2014 62BLOOD AND ITS COMPONENTS
  62. 62. 4/15/2014 BLOOD AND ITS COMPONENTS 63
  63. 63. FUNCTIONS OF PLATELETS • Role in blood clotting – Platelets are responsible for the formation of intrinsic prothrombin activator. This substance is responsible for the onset of clotting. • Role in clot retraction – In the blood clot the blood cells including platelets are entrapped between the fibrin threads. The cytoplasm of the platelets contain the contractile proteins namely actin myosin and thrombosthenin. The contractile proteins are responsible for clot retraction. • Role in repair of ruptured blood vessel – The platelet derived growth factor formed in cytoplasm of platelets is useful for the repair of the endothelium and other structures of the ruptured blood vessels. • Role in defense mechanism – By the property of agglutination, platelets encircle the foreign bodies and kill them by the process of phagocytosis. 4/15/2014 64BLOOD AND ITS COMPONENTS
  64. 64. • Fate of platelets – The life span of platelets is 10 days. Platelets are destroyed by tissue macrophage system in spleen. – So in Splenomegaly there is decrease in platelet count and in Splenectomy there is increased platelet count. 4/15/2014 65BLOOD AND ITS COMPONENTS
  65. 65. Platelet disorders • Thrombocytopenia – Decrease in platelet count Occurs in following conditions: – Acute infections – Acute leukemia – Aplastic and pernicious anemia – Chicken pox – Smallpox – Splenomegaly – Scarlet fever – Tuberculosis – Typhoid – Purpura 4/15/2014 66BLOOD AND ITS COMPONENTS
  66. 66. • Thrombocytosis – Increase in platelet count Seen in – Allergic conditions – Asphyxia – Hemorrhage – Bone fractures – Surgical operations – Splenectomy – Rheumatic fever – Trauma 4/15/2014 67BLOOD AND ITS COMPONENTS
  67. 67. Thrombocythemia • Condition with persistent and abnormal increase in the platelet count – Carcinoma – Chronic disease – Hodgkin’s disease 4/15/2014 68BLOOD AND ITS COMPONENTS
  68. 68. Glanzmann thrombasthenia • Inherited hemorrhagic disorder caused by the structural or functional abnormality of platelets. • Platelet count is normal • Characterized by normal clotting time, normal or prolonged bleeding time but defective clot retraction 4/15/2014 69BLOOD AND ITS COMPONENTS
  69. 69. Hemostasis • Arrest or stoppage of bleeding • Three stages – Vasoconstriction – Platelet plug formation – Coagulation of blood 4/15/2014 70BLOOD AND ITS COMPONENTS
  70. 70. Coagulation of blood 4/15/2014 71BLOOD AND ITS COMPONENTS
  71. 71. Conversion of prothrombin to thrombin 4/15/2014 72BLOOD AND ITS COMPONENTS
  72. 72. Extrinsic pathway 4/15/2014 73BLOOD AND ITS COMPONENTS
  73. 73. Intrinsic pathway 4/15/2014 74BLOOD AND ITS COMPONENTS
  74. 74. Test for clotting 4/15/2014 75BLOOD AND ITS COMPONENTS
  75. 75. • Bleeding time – The time interval from oozing of blood after a cut or injury till arrest of bleeding. – It is determined by DUKE method using blotting paper or filter paper method. – Normal duration is 3 to 6 minutes. – Prolonged in purpura 4/15/2014 76BLOOD AND ITS COMPONENTS
  76. 76. • Clotting time – The time interval from oozing of blood after a cut injury or till the formation of clot. – Determined by Capillary tube method – Normal duration is 3 to 8 minutes – Prolonged in hemophilia 4/15/2014 BLOOD AND ITS COMPONENTS 77
  77. 77. • Prothrombin time – Time taken by blood to clot after adding tissue thromboplastin to it. – Normal duration is about 12 seconds. – Prolonged in deficiency of prothrombin, and other factors like 1, 5, 7 and 10 – Normal in hemophilia 4/15/2014 78BLOOD AND ITS COMPONENTS
  78. 78. Blood is collected and oxalated so that, the calcium is precipitated and prothrombin is not converted into thrombin, thus, the blood clotting is prevented Large quantity of TTP with calcium is added to the blood. calcium nullifies the effect of oxalate. Thus TTP activates prothrombin and blood clotting occurs. During this procedure the time taken by blood to clot after adding TTP is determined 4/15/2014 79BLOOD AND ITS COMPONENTS
  79. 79. • Partial prothrombin time – The time taken for blood to clot after adding phospholipids and calcium to it. – This test is done to investigate the bleeding disorders and to detect the presence of heparin in patients treated with heparin therapy. – Normal duration is 30 to 50 seconds. – Prolonged in heparin therapy and deficiency of factors like 2, 5, 7, 9, 10, 11, 12. 4/15/2014 80BLOOD AND ITS COMPONENTS
  80. 80. • Thrombin time – The time taken for the blood to clot after adding thrombin to it. – To investigate the presence of heparin in plasma or to detect the fibrinogen abnormalities – Normal duration is 12 to 20 seconds – Prolonged in heparin therapy and during dysfibrinogenimia ( abnormal function of fibrinogen with normal fibrinogen level). 4/15/2014 81BLOOD AND ITS COMPONENTS