BLOOD

Blood is a fluid connective tissue consisting of cells suspended in a liquid fibrous

matrix. Blood consists of 2 components- plasma and formed elements. The cells
are a.k.a. formed elements and the liquid matrix is known as plasma. The formed
elements consist of erythrocytes (red blood cells), leukocytes (white blood cells)
and platelets. If blood is centrifuged, it divides into 3 portions: (1) Plasma makes
up roughly 55%; (2) Packed RBCs make up roughly 45%; and (3) the buffy layer
(containing WBCs and platelets) makes up <1%. The % of blood consisting of
packed RBCs is known as the hematocrit.

Blood’s color ranges from scarlet (oxygen-rich) to dark red (oxygen poor). Its
viscosity is 5x (4.5-5.5g/ml/1g/ml) that of water, due primarily to the presence of
formed elements. Blood pH normally ranges from 7.35-7.45 (slightly alkaline).
Blood temperature is typically 100°F (100.4oF i.e 38oC). Typical blood volume is 4-5
L for females and 5-6 L for males. Blood is 8% of total body weight and 0.85-0.9%
saline.

Blood has 3 main distribution functions: (1) It carries O2 (from lungs) and
nutrients (from GI tract and body stores) to all cells; (2) It carries wastes from all
cells to elimination sites (lungs for CO2; kidneys for nitrogenous wastes); and (3) It
carries hormones (chemical signals) from endocrine organs to target tissues.

Blood has 3 main regulatory functions: (1) It regulates body T° by absorbing and
distributing heat; (2) It maintains body pH by virtue of its many buffers; and (3) It
maintains adequate fluid volume in the body.

Blood has 2 main protective functions: (1) It prevents blood loss by initiating
clotting mechanisms in response to blood vessel damage; and (2) It prevents
infection via WBCs and plasma immune proteins.

Blood plasma is about 55% of blood volume. 90% of plasma is [Link] acts as
a solvent and suspending medium as a constituent of plasma. Solutes dissolved in
plasma include: plasma proteins, nutrients, electrolytes, respiratory gases,
hormones and wastes. Albumin is the most abundant plasma protein (60%). The
liver produces it and its primary function is to maintain plasma osmotic pressure.
It also acts as a buffer and is involved in the transport of steroids and bilirubin.
Globulins are another major type of plasma protein. Many are produced in the
liver and act as transport proteins for lipids, metal ions, and fat-soluble vitamins.
Other globulins, known as antibodies are produced during the immune response.
Plasma also contains clotting proteins. Serum= Plasma-clotting factors. Most
clotting proteins are produced in the liver. Two important examples are
prothrombin and fibrinogen. Plasma contains nutrients –absorbed from the GI
tract or body reserves and distributed throughout the body. Examples include
amino acids, glucose, fatty acids, triglycerides, vitamins, and cholesterol. Plasma
also contains electrolytes (ions, such as Ca2+, Na+, and K+, etc.), respiratory gases
(dissolved CO2, O2, and N2), wastes (byproducts of cell metabolism, e.g., urea,
uric acid, ammonia, creatinine, and lactic acid), buffers (chemicals that function to
prevent fluctuations in plasma pH), and hormones (chemical messengers such as
insulin or epinephrine).

Red blood cells are small (7.5µm diam.), biconcave discs. The biconcave shape
gives them a lot of surface area/volume ratio (good for O2 entry/exit) and
increased flexibility (good for. squeezing through tight capillaries i.e narrow
passgaes). They are anucleate and lack organelles. It has the plasma membrane
and cytoplasm. Basically, they are membranous bags stuffed with hemoglobin
proteins. RBCs typically comprise 45% of blood and there are normally 4-6 million
RBCs per µL of blood. Their primary function is O2 transport. They also play a
minor role in CO2 transport. RBC contains oxygen carrying protein haemoglobin
(Hb) that gives blood its red color which is 1/3 of cell’s weight. Total RBC count in
males- 5.4million/µl and for females 4.8million/µl.

Hemoglobin is contained in abundance within RBCs. A small amount is also

dissolved in plasma. It reversibly binds and releases O2. Hb is made up of a
protein (globin) bound to red heme pigments. Globin consists of four polypeptide
chains (2 alpha chains and 2 beta chains), each with their own heme. Each heme
contains one Fe atom that can reversibly bind one O2 molecule. Thus, each Hb
can transport four O2 molecules. In lungs, Hb binds O2 and is then
oxyhemoglobin. In tissues, Hb releases O2 and is then deoxyhemoglobin or
reduced hemoglobin. About 20% of blood’s CO2 is transported by combining with
Hb’s amino acids. Hemoglobin carrying CO2 is known as carbaminohemoglobin.
Many gases O2,CO2,CO,NO bind to the heme portion of the haemoglobin
molecule. Production of abnormal haemoglobin can result in serious blood
sisorders like thalassemia and sickle cell anemia.

Blood cell formation is known as hemopoiesis or hematopoiesis. It occurs in red

bone marrow. Adult red marrow is found in ribs, vertebrae, sternum, pelvis,
proximal humeri, and proximal femurs. RBC formation is known as
erythropoiesis. All blood cells arise from a hemopoietic stem cell
(hemocytoblast). During erythropoiesis, a hemocytoblast divides and
differentiates. Its nucleus and organelles are discarded while Hb stores are built
up to tremendous levels. Erythropoiesis requires iron and vitamin B12.

The number of RBCs in blood is remarkably constant and maintained via negative
feedback. Too few RBCs( as a result of anaemia or not enough haemoglobin)
compromises O2 transport, while too many RBCs (polycythemia over 65% RBC)
cause a detrimental change in blood viscosity. A kidney hormone, erythropoietin
(EPO), controls the rate of erythropoiesis. O2 delivery to the kidney could change
due to RBC count, altitude, increased aerobic activity, lung disease, or CV disease.
After formation an RBC travels thru the circulatory system (arteries, capillaries,
and veins) and after about 120d, it will have become old and/or damaged. The
lack of a nucleus and organelles precludes replication or self-repair. Old/damaged
RBCs are engulfed by scavenger cells, known as macrophages, in the spleen, liver,
and red bone marrow. The Hb within the phagocytosed RBC will be broken down
and partially recycled and partially excreted. Hb is broken down into its globin and
heme portions. The globin is reduced to amino acids, which are released from the
macrophage into the blood stream for reuse elsewhere. Iron is removed from
heme and then transported to the liver by a plasma protein, transferrin. In the
liver, iron is stored as ferritin or hemosiderin. The remainder of the heme is
converted into a pigment called bilirubin. Bilirubin is released from the
macrophage and transported to the liver by albumin. The liver then modifies
bilirubin and secretes it into the small intestine as part of bile. In the intestine,
bilirubin is metabolized by resident bacteria producing metabolites that are
ultimately excreted in the feces and urine.

WBCs (leukocytes)are the only formed elements with nuclei and normal
organelles – thus they’re the only “true cells.” They account for far less than 1%
of total blood volume. They help protect the body from pathogens, toxins, and
cancerous cells. Like RBCs, WBCs are formed in red bone marrow from
hemocytoblasts. Their normal range is 5000-10,000 per µL of blood. Only a small
fraction of the body’s total WBCs are found in the blood at any one time. Most
are in lymphatic organs (e.g., lymph nodes, spleen, tonsils, and appendix) and
within the loose connective tissue that underlies the reproductive, respiratory,
digestive, and urinary tracts. They use the blood to travel from place to place.
They perform Diapedesis (i.e., leave the blood stream) and enter connective or
lymphatic tissue where they mount an immune response. They are capable of
flowing thru the tissue spaces with an amoeboid-like motion. They’re also capable
of following chemical cues released by pathogens, damaged cells, or activated
WBCs. This is known as positive chemotaxis. There are 5 types of WBCs:
neutrophils, lymphocytes, monocytes, eosinophils, and basophils. WBCs are
divided into 2 large classes: granulocytes and agranulocytes. Granulocytes
contain membrane-bound granules that are stained with a dye known as Wright’s
stain. Agranulocytes lack stainable granules.

Granulocytes include neutrophils, eosinophils, and basophils. All are spherical,

larger than RBCs, have lobed nuclei, and stain specifically with Wright’s stain.
Neutrophils are the most numerous circulating WBC. They constitute 50-70% of
the circulating WBC population. They’re 2x the size of RBCs and have a lifespan of
6hrs to a few days. They contain fine lilac colored granules that take up both
acidic and basic dyes, and the nucleus can consist of 3-6 lobes - because of this,
they are often said to be polymorphonuclear. Neutrophil count increases during
acute bacterial infections.

Eosinophils make up 2-4% of the circ. WBC pop. They’re the same size as
neutrophils and have bilobed nuclei. They take up acidic dyes, which cause their
granules to turn reddish orange. A main function is attacking parasitic worms.
They’ll gather around a worm and release enzymes from their granules onto its
surface, killing it. They also lessen the severity of allergies by phagocytosing the
immune complexes involved in allergy attacks. They have a lifespan of 8-12d.

Basophils make up <1% of the circ. WBC pop. They take up basic dyes, which
cause their granules to turn a dark purple. Their granules contain the vasodilator
histamine as well as the anticoagulant heparin. Both are released during
inflammation. They can live for up to several days.

Agranulocytes (lymphocytes and monocytes) lack any visible granules b/c they do
not take up Wright’s stain. Lymphocytes comprise 30% of the circ. WBC pop.
They have large, round, purple nuclei taking up most of the cell volume. They are
1-2x the size of an RBC and have a lifespan of hrs to yrs. There are trillions of
lymphocytes in the body, but only a relatively small number in the blood. Most
are found within lymphatic tissues (e.g., lymph nodes, spleen). There are 2 main
types of lymphocytes. T lymphocytes defend against virus-infected and tumor
cells, and control and manage the immune response. B lymphocytes differentiate
into plasma cells, which produce antibodies. The natural killer cells are also a type
of lymphocytes.

Monocytes comprise 3-8% of the circ. WBC pop. They’re the largest leukocyte –
up to 3x the size of an RBC. They have a lifespan of several months. They contain
pale blue cytoplasm and a dark U or kidney-shaped nucleus. Monocytes leave the
bloodstream to become macrophages – cells specialized in phagocytosis of
foreign particles and [Link] synthesis is known as leukopoiesis. It primarily
occurs within the red marrow. The stem cell for all WBCs is the hemocytoblast.
Lymphocytes can also be produced within lymphatic tissues. Leukocytosis refers
to a high white blood cell count as a result of microbes, strenuous exercise, and
anesthesia/surgery whereas leucopenia refers to a low WBC count as a result of
radiation, shock or chemotherapy.

Platelets (thrombocytes) are fragments (disc-shaped, 2-4 µm diam with no

nucleus.) of extremely large bone marrow cells (megakaryocytes) that are derived
from hemocytoblasts. Platelets contain membrane-bound granules filled with
chemicals involved in blood clotting. They help form blood clots and temporary
patches (platelet plugs) for torn blood vessels. There are typically 150,000-
400,000 platelets per µL of blood. Platelet formation (thrombopoiesis) occurs in
the red marrow, begins with hemocytoblasts, and is stimulated by a hormone
called thrombopoietin. Platelets live for about 10-12d. Hemostasis is the set of
processes that stop bleeding and help heal damaged blood vessel walls. It
prevents haemorrhage i.e loss of a large amount of blood. It consists of 3 events:
vascular spasm, platelet plug formation, and coagulation.

During vascular spasm, damaged vessels release chemicals that cause the smooth
muscle in their walls to contract. Blood loss and local blood pressure will hence be
affected (thus facilitating patching and repair). Platelets are activated when the
tearing of a blood vessel wall exposes the collagen that underlies the vessel’s
endothelium (i.e., its simple squamous epithelial lining). Activated platelets then
aggregate at the injury site. Aggregated, activated platelets release chemicals
that: enhance vascular spasm; are involved in coagulation; and facilitate the
activation and aggregation of more platelets at the injury site which promotes
blood clotting. The pile of aggregated platelets is a platelet plug and provides a
temporary seal to the break in the vessel wall. The platelet plug is restricted to
the injury site because intact endothelial cells release the chemical prostacyclin,
which inhibits platelet aggregation.

Blood contains chemicals known as procoagulants (which initiate and stimulate

the formation of a blood clot) and chemicals known as anticoagulants (which
inhibit and impede the formation of a blood clot). When vessels are intact, the
anticoagulants “win” and clotting does not occur. However, blood vessel damage
sets off a chain of events whereby the procoagulants dominate and coagulation
occurs.

Coagulation is a complicated multi-step process that results in the formation of a

sturdy clot that seals the tear until repairs are complete. In response to vessel
damage, prothrombin activator (PTA) is formed. PTA converts the inactive plasma
protein prothrombin into the active thrombin. Thrombin converts the insoluble
plasma protein fibrinogen into the insoluble fibrin. Fibrin molecules then link to
one another and form a meshwork of strands on the platelet plug. RBCs, WBCs,
and plasma are trapped within the fibrin mesh. This is a blood clot.

There are 2 pathways by which PTA is formed: extrinsic and intrinsic. The extrinsic
path begins when blood is exposed to a chemical released by damaged tissue cells
outside the blood vessel. The extrinsic path has few steps and thus PTA can be
formed quickly. The intrinsic path begins in response to the release of certain
chemicals by damaged blood vessel cells. The intrinsic path has many steps. This
makes it slower than the extrinsic path, but it allows for amplification, which
yields tremendous amounts of PTA. In the body, both pathways typically occur in
response to the same event. Having 2 pathways allows for PTA to be formed
quickly (extrinsic) as well as in large amounts (intrinsic).

Multiple clotting factors are involved in the coagulation process. Many of these
are formed in the liver. Vitamin K is required for their synthesis. Calcium is also
required for [Link] the clot has formed, clot retraction will occur.
Platelets contain actin and myosin. They contract, compacting the clot and pulling
the edges of the torn vessel together (facilitating repair). The contraction
squeezes serum (plasma minus clotting factors) from the clot. Meanwhile the
vessel begins healing. PDGF (platelet-derived growth factor) and VEGF (vascular
endothelial growth factor) stimulate smooth muscle cells and fibroblasts to
rebuild the vessel [Link] plasma protein, plasminogen, is involved in
fibrinolysis – the breakdown of the [Link] is converted to plasmin by
tissue plasminogen activator. Plasmin digests fibrin once repairs have taken
[Link] are restricted from growing too large by the removal of clotting factors
as well as the presence of normal anticoagulant chemicals. Coagulation can be
promoted by roughened vessel lining, which can attract and activate platelets.
Also, pooling of blood within blood vessels can result in the activation of clotting
factors and the initiation of the coagulation process.

Blood Groups and Blood Types

To prevent antigen‐antibody reaction we need to have knowledge of blood

groups and blood types.
 Red cells carry an antigen that reacts with the corresponding antibody in the
plasma of individuals of certain other groups. If the cells are transfused into an
individual with the equivalent antibody in his plasma, they are rapidly destroyed,
with serious consequences. Although some 9 blood groups are known, only the
ABO and Rh are of major importance as causes of haemolytic transfusion
reactions

The first sign of the haemolytic antigen‐antibody reaction is agglutination and,

therefore, red‐cell antigens and plasma antibodies are called agglutinogens or
agglutinins respectively. The agglutinated cells haemolyse, freeing haemoglobin
and other constituents and causing jaundice and kidney damage: if the latter is
extreme, the patient may even die. Fortunately most transfusion reactions are
mild.

In the ABO system, antigens A and B determine blood types. blood type A has
antigen A only, blood type B has antigen B only, blood type AB has antigen A and
B and blood type O has neither of the antigen.

Plasma naturally contains antibodies (agglutinins) at birth that react with antigens
that are foreign to the individual: anti-A antibody reacts with antigen A (Only
found in type B and O individuals), anti-B antibody reacts with antigen B (Only
found in type A and O individuals).Type AB individuals have no [Link]
with type AB blood called “universal recipients” since have no antibodies in
plasma. People with type O blood cell called “universal donors” since have no
antigens on their cells theoretically can be given to anyone. Generally, the
recipient’s cells are not seriously harmed by the agglutinins in the donor’s plasma,
because the latter quickly becomes diluted in the recipient’s blood (thus a donor
of blood group O can donate to all even though it has agglutinins Anti‐A and Anti‐
B)
Group Red cell Plasma Can donate Can
Antigen{Agglutinogen Antibody{Agglutinin} to receive
from
A A Anti B A or AB A or O
B B Anti A B or AB B or O
AB A and B None AB only All groups
{Universal
recipient}
O O Anti A and Anti B All groups O only
{Universal
donor}

Rhesus group

Antigen was discovered in blood of Rhesus monkey. People with Rh antigens on

RBC surface are Rh+. Normal plasma contains no anti-Rh antibodies. If Rh+ blood
is transfused into an Rh‐recipient, production of antibodies to the Rh+ blood may
be stimulated. If this occurs, subsequent transfusion of Rh+ blood will cause a
haemolytic reaction .Antibodies for example develop only in Rh- blood type &
only with exposure to the antigen transfusion of positive blood during a
pregnancy with a positive blood type fetus and Transfusion reaction upon 2nd
exposure to the antigen results in hemolysis of the RBCs in the donated blood.
Haemolytic disease in a new born can result If a foetus is Rh+ from it’s father, and
the mother is Rh‐ and has the Rh+ antibody in her blood (either from previous
transfusion of Rh+ blood or as a result of stimulation by antigens of the foetus),
the mother’s antibodies may cross the placenta and destroy the foetal
[Link] haemolytic reaction may kill the foetus or cause the infant to be
severely anaemic. Rh negative mom and Rh+ fetus will have mixing of blood at
birth. Mom's body that is RH negative creates Rh antibodies unless she receives a
RhoGam shot soon after first delivery, miscarriage or abortion. RhoGam binds to
loose fetal blood and removes it from body before she reacts although In 2nd
child, hemolytic disease of the newborn may develop causing hemolysis of the
fetal RBCs.

Blood Products

They include

1 Whole blood- This is the human blood mixed with a suitable

anticoagulant{ heparin, citrates, Disodium edatate}. The shelf life of whole blood
is 42 days but it is used in 21 days. Platelets and clotting factors are quickly
depleted on storage. One unit of blood transfusion can raise hemoglobin by 7%

2 Packed cells- Packed red blood cells are useful in treating chronic anemia in old
people and patients with cardiovascular disability. In Acute hemorrhage packed
and washed red blood cells are useful after reconstituting with isotonic saline
solution.

3 Fresh frozen plasma- It contains all clotting factors except platelets hence they
are useful in bleeding disorders.

4 Albumin{ 5%/ 25% in saline}- Useful in burns, nephrotic syndrome, liver cirrhosis
etc

5 Platelet concentrate- It is indicated in thrombocytopaenia. A low platelet count

is below 150,000 {150x 109/L}. The normal number of platelets in the blood is
150,000-400,000 platelets per microliter {mcL} or 150-400x10 9/L

6 Specific coagulation factors VII, VIII, IX and X

7 Cryoprecipitate- This product is used to prevent or control bleeding in people

whose blood does not clot properly eg patients with serious but rare hereditary
conditions such as Hemophilia A {who lack factor VIII}.

8 SAG mannitol blood- It is useful in chronic anaemia. It is prepared by removing a

proportion of blood plasma and replacing with 100ml of crystalloid solution
containing sodium chloride, adenine, glucose anhydrous, mannitol.