Blood 1

1. Good Morning

2. Blood and its components Dr. Nitika Jain

3. contents Introduction Properties of blood Composition of blood Functions of blood Red blood cells Erythropoiesis 9/10/2012 3 BLOOD AND ITS COMPONENTS

4. Erythrocyte sedimentation rate White blood cells Platelets 9/10/2012 4 BLOOD AND ITS COMPONENTS

5. Coagulation of blood Test for clotting Bleeding time Clotting time Prothrombin time Partial Prothrombin time Thrombin time Bleeding disorders 9/10/2012 5 BLOOD AND ITS COMPONENTS

6. introduction Connective tissue in fluid form Fluid of life Fluid of growth Fluid of health 9/10/2012 6 BLOOD AND ITS COMPONENTS

7. Properties of blood Color Volume Reaction and pH Specific gravity Viscosity 9/10/2012 7 BLOOD AND ITS COMPONENTS

8. Composition of blood Blood cells RBC WBC Platelets Plasma Serum 9/10/2012 8 BLOOD AND ITS COMPONENTS

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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). 9/10/2012 10 BLOOD AND ITS COMPONENTS

11. Composition of plasma 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 1/6 th of total buffering action of blood. 9/10/2012 11 BLOOD AND ITS COMPONENTS

12. Functions of blood 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 9/10/2012 12 BLOOD AND ITS COMPONENTS

13. Red blood cells 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 9/10/2012 13 BLOOD AND ITS COMPONENTS

14. Morphology of RBC 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 9/10/2012 14 BLOOD AND ITS COMPONENTS

15. Properties of RBC 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. 9/10/2012 15 BLOOD AND ITS COMPONENTS

16. Functions of RBC 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 9/10/2012 16 BLOOD AND ITS COMPONENTS

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18. Variation in number of RBC Physiological variation s 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. 9/10/2012 18 BLOOD AND ITS COMPONENTS

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23. Pathological variations Pathological polycythemia RBC count increases 7millions/cc of blood Two types: 1.Primary 2.Secondary 9/10/2012 23 BLOOD AND ITS COMPONENTS

24. Primary polycythemia 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 9/10/2012 24 BLOOD AND ITS COMPONENTS

25. Secondary polycythemia 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 9/10/2012 25 BLOOD AND ITS COMPONENTS

26. Erythropoiesis Process of origin, development and maturation of erythrocytes. 9/10/2012 26 BLOOD AND ITS COMPONENTS

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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 9/10/2012 28 BLOOD AND ITS COMPONENTS

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 9/10/2012 29 BLOOD AND ITS COMPONENTS

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32. RBCs after 120 days Fragile Membranes of RBC rupture Phagocytized by Reticulo endothelial system Tissue macrophages Kupffer cells Spleen FATE OF RBC 9/10/2012 32 BLOOD AND ITS COMPONENTS

33. Hemoglobin split Heme Globin Amino acid pool- reuse Free Iron Straight chain of 4 pyrole nuclei Transported in blood by transferrin Reused 9/10/2012 33 BLOOD AND ITS COMPONENTS

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 9/10/2012 34 BLOOD AND ITS COMPONENTS

35. Erythrocyte sedimentation rate The rate at which the erythrocytes settle down. Methods: Westergren’s method Wintrobe’s method 9/10/2012 35 BLOOD AND ITS COMPONENTS

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 9/10/2012 36 BLOOD AND ITS COMPONENTS

37. Variation in ESR Physiological variation Age – less in children and infants Gender – more in females than in males Menstruation – increases because of loss of blood Pregnancy – from 3 rd to paturition ESR increases because of hemodilution 9/10/2012 37 BLOOD AND ITS COMPONENTS

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 9/10/2012 38 BLOOD AND ITS COMPONENTS

39. Significance of determining ESR 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 9/10/2012 39 BLOOD AND ITS COMPONENTS

40. Factors effecting ESR 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. 9/10/2012 40 BLOOD AND ITS COMPONENTS

41. 9/10/2012 BLOOD AND ITS COMPONENTS 41 GOOD MORNING

42. Hemoglobin 9/10/2012 BLOOD AND ITS COMPONENTS 42

43. Hemoglobin Hb is the iron containing coloring matter of RBC The main function of red cells is to carry O 2 to the tissues and to return carbon dioxide (CO 2 ) 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. 9/10/2012 BLOOD AND ITS COMPONENTS 43

44. Normal hemoglobin content Average Hb in blood is 14 to 16g/ dL Age At birth – 25g/ dL After 3 rd 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 9/10/2012 BLOOD AND ITS COMPONENTS 44

45. Functions of HB 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 9/10/2012 BLOOD AND ITS COMPONENTS 45

46. Structure of hb 9/10/2012 BLOOD AND ITS COMPONENTS 46

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 9/10/2012 BLOOD AND ITS COMPONENTS 47

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49. B B A A heme Hemoglobin structure 9/10/2012 49 BLOOD AND ITS COMPONENTS

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51. Hb A Hb A 2 Hb F structure a 2 b 2 a 2 d 2 a 2 g 2 Normal % 96-98 % 1.5-3.2 % 0.5-0.8 % Adult haemoblobin 9/10/2012 51 BLOOD AND ITS COMPONENTS

52. Haemoglobin synthesis Haem synthesis starts with the condensation of glycine and succinyl coenzyme A under the action of a rate limiting enzyme d - aminolaevulinic acid synthase . d -ALA will be formed. Pyridoxal phosphate ( vit . B 6 ) is a coenzyme for this reaction. 9/10/2012 52 BLOOD AND ITS COMPONENTS

53. Haemoglobin synthesis A series of biochemical reactions will follow. Two molecules of d -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 . 9/10/2012 53 BLOOD AND ITS COMPONENTS

54. Haemoglobin synthesis CPG then changes to protoporphyrin which ultimately combines with iron in the ferrous state (Fe 2+ ) 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. 9/10/2012 54 BLOOD AND ITS COMPONENTS

55. Haemoglobin synthesis 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. 9/10/2012 55 BLOOD AND ITS COMPONENTS

56. Hemoglobin split Heme Globin Amino acid pool- reuse Free Iron Straight chain of 4 pyrole nuclei Transported in blood by transferrin Reused 9/10/2012 56 BLOOD AND ITS COMPONENTS

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 9/10/2012 57 BLOOD AND ITS COMPONENTS

58. Bile pigments and jaundice 58 9/10/2012 BLOOD AND ITS COMPONENTS

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69. Abnormal hb Hemoglobinopathies Hemoglobin in thalassemia and related disorders 9/10/2012 BLOOD AND ITS COMPONENTS 69

70. hemoglobinopathies 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 9/10/2012 BLOOD AND ITS COMPONENTS 70

71. HB in thalessemia and related disorders Abnormal Hb are present Polypeptide chains are decreased 9/10/2012 BLOOD AND ITS COMPONENTS 71

72. thalassemia 9/10/2012 BLOOD AND ITS COMPONENTS 72

73. What Is Thalassemia? 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. 9/10/2012 73 BLOOD AND ITS COMPONENTS

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. 9/10/2012 74 BLOOD AND ITS COMPONENTS

75. The two main types of thalassemia A lpha 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. 9/10/2012 75 BLOOD AND ITS COMPONENTS

76. Alpha Thalassemia 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. 9/10/2012 76 BLOOD AND ITS COMPONENTS

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. 9/10/2012 77 BLOOD AND ITS COMPONENTS

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. 9/10/2012 78 BLOOD AND ITS COMPONENTS

79. Beta Thalassemia 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. 9/10/2012 79 BLOOD AND ITS COMPONENTS

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. 9/10/2012 80 BLOOD AND ITS COMPONENTS

81. Who Is At Risk for Thalassemia? Thalassemia is passed from parents to children through their genes. Thalassemia affects both males and females. Beta thalassemias affect people of Mediterranean origin or ancestry (Greek, Italian, Middle Eastern) and people of Asian and African descent. Alpha thalassemias mostly affect people of Southeast Asian, Indian, Chinese, or Filipino origin or ancestry. 9/10/2012 81 BLOOD AND ITS COMPONENTS

82. What Are the Signs and Symptoms of Thalassemia? 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 ). 9/10/2012 82 BLOOD AND ITS COMPONENTS

83. In more severe types of thalassemia, such as Cooley ’ s anemia , signs of the severe anemia are seen in early childhood and may include: Fatigue (feeling tired) and weakness Pale skin or jaundice (yellowing of the skin) Protruding abdomen, with enlarged spleen and liver Dark urine 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 9/10/2012 83 BLOOD AND ITS COMPONENTS

84. How Is Thalassemia Diagnosed? Thalassemia is diagnosed using blood tests, including a complete blood count (CBC) and special hemoglobin studies. 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. Hemoglobin studies measure the types of hemoglobin in a blood sample. 9/10/2012 84 BLOOD AND ITS COMPONENTS

85. Cooley ’ s anemia 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. 9/10/2012 85 BLOOD AND ITS COMPONENTS

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. 9/10/2012 86 BLOOD AND ITS COMPONENTS

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. 9/10/2012 87 BLOOD AND ITS COMPONENTS

88. How Is Thalassemia Treated? 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. 9/10/2012 88 BLOOD AND ITS COMPONENTS

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 . 9/10/2012 BLOOD AND ITS COMPONENTS 89

90. Those with severe thalassemia have a serious and life-threatening illness. They are treated with regular blood transfusions, iron chelation therapy , and bone marrow transplants. Without treatment, children with severe thalassemia do not live beyond early childhood. 9/10/2012 90 BLOOD AND ITS COMPONENTS

91. Blood Transfusions 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. 9/10/2012 91 BLOOD AND ITS COMPONENTS

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. 9/10/2012 92 BLOOD AND ITS COMPONENTS

93. Iron Chelation Therapy 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. 9/10/2012 93 BLOOD AND ITS COMPONENTS

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. 9/10/2012 94 BLOOD AND ITS COMPONENTS

95. Surgery 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. 9/10/2012 95 BLOOD AND ITS COMPONENTS

96. Bone Marrow or Stem Cell Transplants 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. 9/10/2012 96 BLOOD AND ITS COMPONENTS

97. Other Treatments 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. 9/10/2012 97 BLOOD AND ITS COMPONENTS

98. Red blood cell indices and packed cell volume 9/10/2012 BLOOD AND ITS COMPONENTS 98

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 ). 9/10/2012 99 BLOOD AND ITS COMPONENTS

100. Mean Corpuscular Volume 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 . 9/10/2012 100 BLOOD AND ITS COMPONENTS

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. 9/10/2012 101 BLOOD AND ITS COMPONENTS

102. Mean Corpuscular Hemoglobin (MCH) The MCH is the average weight of Hb in an RBC, expressed in the units of picograms (pg), or 10 -12 g: 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 9/10/2012 102 BLOOD AND ITS COMPONENTS

103. Mean Corpuscular Hemoglobin Concentration (MCHC) 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 9/10/2012 103 BLOOD AND ITS COMPONENTS

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. 9/10/2012 104 BLOOD AND ITS COMPONENTS

105. Packed Cell Volume of Whole Blood 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). 9/10/2012 105 BLOOD AND ITS COMPONENTS

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. 9/10/2012 106 BLOOD AND ITS COMPONENTS

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 9/10/2012 107 BLOOD AND ITS COMPONENTS

108. Procedure : 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. Seal the end of the tube with the colored ring with nonabsorbent clay 9/10/2012 108 BLOOD AND ITS COMPONENTS

109. Balance the tubes in the centrifuge with the clay ends facing the outside away from the center, touching the rubber gasket. Tighten the head cover on the centrifuge and close the top. Activate the centrifuge for 5 minutes between 10,000 and 15,000 rpm Determine the HCT by using a microhematocrit reading device Read the level of RBC packing. The values of the two Hcts should agree within 2% (0.02). 9/10/2012 109 BLOOD AND ITS COMPONENTS

110. Hematocrite Reader Reference ranges: Newborn 53-65% Infant/child 30-43% Adult male 42-52% Adult female 37-47% 9/10/2012 110 BLOOD AND ITS COMPONENTS

111. anemia 9/10/2012 BLOOD AND ITS COMPONENTS 111

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114. Morphological classification 9/10/2012 114 BLOOD AND ITS COMPONENTS

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116. Etiological classification 9/10/2012 116 BLOOD AND ITS COMPONENTS

117. Hemorrhagic anemia 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 9/10/2012 117 BLOOD AND ITS COMPONENTS

118. Hemolytic anemia Excessive destruction of RBC Two types: Extrinsic Liver failure Renal disorder Hypersplenism Burns Infections Intrinsic Generally inherited like sickle cell anemia and thalassemia 9/10/2012 118 BLOOD AND ITS COMPONENTS

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 9/10/2012 119 BLOOD AND ITS COMPONENTS

120. Clinical features 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. 9/10/2012 BLOOD AND ITS COMPONENTS 120

121. Patho physiology of sickle cell anemia 9/10/2012 121 BLOOD AND ITS COMPONENTS

122. Nutrition deficiency anemia Iron deficiency anemia Pernicious anemia/ Addison’s anemia Megaloblastic anemia 9/10/2012 122 BLOOD AND ITS COMPONENTS

123. IRON DEFICIENCY ANEMIA 9/10/2012 123 BLOOD AND ITS COMPONENTS

124. IRON DEFICIENCY ANEMIA Prevalence 9/10/2012 124 BLOOD AND ITS COMPONENTS

125. IRON 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 O 2 Organisms able to limit exposure to iron had major survival advantage 9/10/2012 125 BLOOD AND ITS COMPONENTS

126. Causes of Iron Deficiency anemia 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 9/10/2012 126 BLOOD AND ITS COMPONENTS

127. IRON DEFICIENCY ANEMIA Progression of Findings 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 9/10/2012 127 BLOOD AND ITS COMPONENTS

128. IRON DEFICIENCY Symptoms Fatigue - Sometimes out of proportion to anemia Atrophic glossitis Pica Koilonychia (Nail spooning) Esophageal Web 9/10/2012 128 BLOOD AND ITS COMPONENTS

129. MANAGEMENT OF IDA 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 ) 9/10/2012 129 BLOOD AND ITS COMPONENTS

130. PREVENTION OF IDA Dietary modification Food fortification Iron supplementation 9/10/2012 130 BLOOD AND ITS COMPONENTS

131. PREVENTION OF IDA 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 9/10/2012 131 BLOOD AND ITS COMPONENTS

132. PREVENTION OF IDA S hort term approach : s upplementation with iron tablets . L ong-term approach : f ood 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. 9/10/2012 132 BLOOD AND ITS COMPONENTS

133. FOOD FORTIFICATION 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 ). 9/10/2012 133 BLOOD AND ITS COMPONENTS

134. Which iron form to use? The major factors governing the choice of iron compound include: Bioavailability Organoleptic problems Cost Saf ety Ideally we should go for a safe, cheap, highly bioavailable iron, which causes no organoleptic side-effects 9/10/2012 134 BLOOD AND ITS COMPONENTS

135. Which iron form to use? 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 9/10/2012 135 BLOOD AND ITS COMPONENTS

136. Megaloblastic anemia 9/10/2012 BLOOD AND ITS COMPONENTS 136

137. 137 MEGALOBLASTIC ANEMIAS - Causes 1. Vit. B 12 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. 9/10/2012 BLOOD AND ITS COMPONENTS

138. 138 VITAMIN B 12 AND FOLIC ACID-PHYSIOLOGIC CONSIDERATIONS V itamin B 12 F olic 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 9/10/2012 BLOOD AND ITS COMPONENTS

139. Pernicious anemia 9/10/2012 BLOOD AND ITS COMPONENTS 139

140. Pernicious anemia 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. 9/10/2012 BLOOD AND ITS COMPONENTS 140

141. Clinical features 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 9/10/2012 BLOOD AND ITS COMPONENTS 141

142. Lab. Findings 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. 9/10/2012 BLOOD AND ITS COMPONENTS 142

143. treatment Replacement therapy with vitamin B12 Vitamin B 12 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, I f Fe deficiency is diagnosed we should start iron substitution 100 ug vit.B 12 i.m. every month, regimen that must be maint ain e d for the rest on the patients life. Physiotherapy for neurologic deficits and occasionally blood transfusion Follow up early detection of cancer of the stomach 9/10/2012 BLOOD AND ITS COMPONENTS 143

144. Folic acid deficiency anemia 9/10/2012 BLOOD AND ITS COMPONENTS 144

145. 145 Causes of Folic acid deficiency 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, N 2 ) 9/10/2012 BLOOD AND ITS COMPONENTS

146. 146 MEGALOBLASTIC ANEMIAS clinical features 1. Symptoms of anemia 2. Symptoms associated with vit. B 12 or Folic acid deficiency neurologic manifestations (exclusivly in wit. B 12 deficiency) - megaloblastic madness or psychosis, - subacute, combined degeneration of the spinal cord (proprioceptive and vibratory sensation , spina l ataxia ) gastrointestinal compraints (vit.B 12 and folic acid deficiency) - loss of appetite - glosstis (red, sore, smooth tongue) - diarrhea or constipation 9/10/2012 BLOOD AND ITS COMPONENTS

147. 147 MEGALOBLASTIC ANEMIAS Diagnosis 1. Blood cell count: macrocytic anemia thrombocytopenia leucopenia (granulocytopenia) low reticulocyte count 2. Blood smear: hypersegmentation of granulocytes macroovalocy tes , anisocytosis, poikilocytosis 9/10/2012 BLOOD AND ITS COMPONENTS

148. 148 MEGALOBLASTIC ANEMIAS Diagnosis 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 9/10/2012 BLOOD AND ITS COMPONENTS

149. 149 FOLIC ACID DEFICIENCY ANEMIA DIAGNOSIS 1. Establishing megaloblastic anemia 2. History: causes of folate deficiency 3. Absence neurologic symptoms 4. Low serum and red blood cell folic acid 9/10/2012 BLOOD AND ITS COMPONENTS

150. 150 MEGALOBLASTIC ANEMIAS TREATMENT FOLIC ACID DEFICIENCY ANEMIA 1. Oral administration of Ac. folicum 1 (5) mg per day, for 3 months, and maint en ance therapy if it’s necessary. 2. Reticulocytosis after 5-7 days 3. Correction of anemia is over after 1-2 months th erapy 4. Maintenance therapy if necessary 9/10/2012 BLOOD AND ITS COMPONENTS