LECTURE 8 &9

USE EVALUATION (1)

Blood and blood Analysis
 Functions of Blood
A) Distribution; Blood transports
 Oxygen from the lungs and nutrients from the digestive tract
 Metabolic wastes from cells to the lungs and kidneys for elimination
 Hormones from endocrine glands to target organs
B) Regulation; Blood maintains
 Appropriate body temperature by absorbing & distributing heat to other parts of body
 Normal pH in body tissues using buffer systems
 Adequate fluid volume in the circulatory system
C) Protection;
• Blood prevents blood loss by:
 Activating plasma proteins and platelets
 Initiating clot formation when a vessel is broken
• Blood prevents infection by:
 Synthesizing and utilizing antibodies
 Activating complement proteins
 Activating WBCs to defend the body against foreign invaders
 Physical Characteristics of Blood
 Average volume of blood:
◦ 5–6 L for males; 4–5 L for females (Normovolemia)
◦ Hypovolemia - low blood volume
◦ Hypervolemia - high blood volume
 Viscosity (thickness) - 4 - 5 (where water = 1)
 The pH of blood is 7.35–7.45; x = 7.4
 Osmolarity = 300 mOsm or 0.3 Osm
◦ This value reflects the concentration of solutes in the plasma
 Salinity = 0.85%
◦ Reflects the concentration of NaCl in the blood
 Temperature is 38C, slightly higher than “normal” body temperature
 Blood accounts for approximately 8% of body weight
 Physical Characteristics of Blood
 Average volume of blood:
◦ 5–6 L for males; 4–5 L for females (Normovolemia)
◦ Hypovolemia - low blood volume
◦ Hypervolemia - high blood volume
 Viscosity (thickness) - 4 - 5 (where water = 1)
 The pH of blood is 7.35–7.45; x = 7.4
 Osmolarity = 300 mOsm or 0.3 Osm
◦ This value reflects the concentration of solutes in the plasma
 Salinity = 0.85%
◦ Reflects the concentration of NaCl in the blood
 Temperature is 38C, slightly higher than “normal” body temperature
 Blood accounts for approximately 8% of body weight
 Composition of Blood
• Blood is the body’s only fluid tissue (a connective tissue)
• 2 major components
– Liquid = plasma (55%)
– Formed elements (45%)
• Erythrocytes, or red blood cells (RBCs)
• Leukocytes, or white blood cells (WBCs)
• Platelets - fragments of megakaryocytes in marrow
 Components of Whole Blood

Plasma
(55% of whole blood)

Buffy coat:
leukocyctes and
platelets
(<1% of whole blood)
Formed
elements
Erythrocytes
1 Withdraw blood 2 Centrifuge (45% of whole blood)
and place in tube

• Hematocrit
• Males: 47% ± 5%
• Females: 42% ± 5%
 Blood Plasma
• Blood plasma components:
– Water = 90-92%
– Proteins = 6-8%
• Albumins; maintain osmotic pressure of the blood
• Globulins
– Alpha and beta globulins are used for transport purposes
– Gamma globulins are the immunoglobulins (IgG, IgA, etc)
• Fibrinogen; a clotting protein
– Organic nutrients – glucose, carbohydrates, amino acids
– Electrolytes – sodium, potassium, calcium, chloride, bicarbonate
– Nonprotein nitrogenous substances – lactic acid, urea, creatinine
– Respiratory gases – oxygen and carbon dioxide
 Formed Elements
• Formed elements comprise 45% of blood
• Erythrocytes, leukocytes, and platelets
make up the formed elements
– Only WBCs are complete cells
– RBCs have no nuclei or organelles, and
platelets are just cell fragments
• Most formed elements survive in the
bloodstream for only a few days
• Most blood cells do not divide but are
renewed by cells in bone marrow
 Erythrocytes (RBCs)
• Biconcave disc
– Folding increases surface area (30% more surface area)
– Plasma membrane contains spectrin
• Give erythrocytes their flexibility
• Anucleate, no centrioles, no organelles
– End result - no cell division
– No mitochondria means they generate ATP anaerobically
• Prevents consumption of O2 being transported
• Filled with hemoglobin (Hb) - 97% of cell contents
– Hb functions in gas transport
• Hb + O2 HbO2 (oxyhemoglobin)
• Most numerous of the formed elements
– Females: 4.3–5.2 million cells/cubic millimeter
– Males: 5.2–5.8 million cells/cubic millimeter
Erythrocytes (RBCs)
 Erythrocyte Function
• Erythrocytes are dedicated to respiratory
gas transport
• Hemoglobin reversibly binds with oxygen
and most oxygen in the blood is bound to
hemoglobin
• Composition of hemoglobin
– A protein called globin
• made up of two alpha and two beta chains
– A heme molecule
• Each heme group bears an atom of iron, which can bind
to one oxygen molecule
• Each hemoglobin molecule thus can transport four
molecules of oxygen
 Hemoglobin

• Oxyhemoglobin – hemoglobin bound to oxygen

– Oxygen loading takes place in the lungs
• Deoxyhemoglobin – hemoglobin after oxygen
diffuses into tissues (reduced Hb)
• Carbaminohemoglobin – hemoglobin bound to
carbon dioxide
– Carbon dioxide loading takes place in the tissues
Structure of Hemoglobin
 Fate and Destruction of Erythrocytes

• The life span of an erythrocyte is 100–120 days

– Travels about 750 miles in that time (LA to Albuquerque)
• Old erythrocytes become rigid and fragile, and their
hemoglobin begins to degenerate
• Dying erythrocytes are engulfed by macrophages
• Heme and globin are separated
– Iron is removed from the heme and salvaged for reuse
• Stored as hemosiderin or ferritin in tissues
• Transported in plasma by beta-globulins as transferrinHeme is degraded to a
yellow pigment called bilirubin
– Liver secretes bilirubin into the intestines as bile
– Intestines metabolize bilirubin into urobilinogen
– Urobilinogen leaves the body in feces, in a pigment called stercobilin
• Globin is metabolized into amino acids which are then released
Life Cycle of Red Blood Cells
 Production of Erythrocytes
• Hematopoiesis – blood cell formation
– Occurs in the red bone marrow (myeloid tissue)
• Axial skeleton and girdles
• Epiphyses of the humerus and femur
• Marrow contains immature erythrocytes
• Composed of reticular connective tissue
• Hemocytoblasts give rise to ALL formed elements
– Lymphoid stem cells - give rise to lymphocytes
• A hemocytoblast is transformed into a committed cell called the
proerythroblast
• Proerythroblasts develop into early erythroblasts
• The developmental pathway consists of three phases
– Phase 1 – ribosome synthesis in early erythroblasts
– Phase 2 – hemoglobin accumulation in late erythroblasts and normoblasts
– Phase 3 – ejection of the nucleus from normoblasts and formation of reticulocytes
• Reticulocytes then become mature erythrocytes
– Reticulocytes make up about 1 -2 % of all circulating erythrocytes
– Myeloid stem cells - give rise to all other blood cells
 Hormonal Control of Erythropoiesis
• Erythropoietin (EPO) release by the kidneys is triggered by:
– Hypoxia due to decreased RBCs
– Decreased oxygen availability
– Increased tissue demand for oxygen
• Enhanced erythropoiesis increases the:
– RBC count in circulating blood
– Oxygen carrying ability of the blood
 Erythropoietin Mechanism
Imb
al a
nce
Start
Normal blood oxygen levels Stimulus: Hypoxia due to
Imb decreased RBC count,
ala decreased availability of O2
nce
to blood, or increased
Increases tissue demands for O2
O2-carrying
ability of blood

Reduces O2
levels in blood

Erythropoietin
Kidney (and liver to a
Enhanced stimulates red
smaller extent) releases
erythropoiesis bone marrow
erythropoietin
increases RBC
count
 Erythrocyte Disorders

Anemia
– blood has abnormally low oxygen-
carrying capacity
– It is a symptom rather than a disease
itself
– Blood oxygen levels cannot support
normal metabolism
– Signs/symptoms include fatigue,
paleness, shortness of breath, and chills
 Polycythemia
• Polycythemia – excess RBCs that increase blood viscosity
• Three main polycythemias are:
– Polycythemia vera
– Secondary polycythemia
– Blood doping
 Leukocytes (WBCs)
• Leukocytes, the only blood components that are complete
cells:
– 4,800 - 10,000/cubic millimeter
– Protect the body from infectious microorganisms
– Can leave capillaries via diapedesis
– Move through tissue spaces (amoeboid motion)
– Many are phagocytic (possess numerous lysosomes)
• Two major types of leukocytes
– Granulocytes: Neutrophils, Eosinophils, Basophils
– Agranulocytes: Monocytes, Lymphyocytes
• Leukocytosis – WBC count over 11,000/mm3
– Normal response to bacterial or viral invasion
• Leukopenia - a decrease in WBC count below 4,800/mm3
• Leukemia - a cancer of WBC
 Granulocytes
• Granulocytes – neutrophils, eosinophils, and basophils
– Contain cytoplasmic granules that stain specifically (acidic, basic, or
both) with Wright’s stain
– Are larger and usually shorter-lived than RBCs
– Have lobed nuclei
– Are all phagocytic cells
 Granulocytes: Neutrophils
(Polymorphonuclear leukocytes)
• Account for 65-75% of total WBC’s
• Neutrophils have two types of granules that:
– Take up both acidic and basic dyes
– Give the cytoplasm a lilac color
– Contain peroxidases, hydrolytic enzymes, and defensins (antibiotic-
like proteins)
• Neutrophils are our body’s bacteria slayers
• AKA “polys” or PMN’s (polymorphonuclear)
 Granulocytes: Eosinophils
• Eosinophils account for 1–4% of WBCs
– Have red-staining, bilobed nuclei
– Have red to crimson granules
– Function:
• Lead the body’s counterattack against parasitic infections
• Lessen the severity of allergies by phagocytizing immune complexes (ending
allergic reactions)
 Granulocytes: Basophils
• Account for 0.5-1% of all WBCs
– Have U- or S-shaped nuclei with two or three conspicuous
constrictions
– Are functionally similar to mast cells
– Have large, purplish-black (basophilic) granules that contain
histamine
• Histamine – inflammatory chemical that acts as a vasodilator and attracts
other WBCs (antihistamines counter this effect)
 Agranulocytes: Lymphocytes

• Account for 20-25% or more of WBCs and:

– Have large, dark-purple, circular nuclei with a
thin rim of blue cytoplasm
– Are found mostly enmeshed in lymphoid tissue
(some circulate in the blood)
• Most important cells of the immune system
• There are two types of lymphocytes: T cells
and B cells
– T cells - attack foreign cells directly
– B cells give rise to plasma cells, which produce
antibodies
 Monocytes
• Monocytes account for 3–7% of leukocytes
– They are the largest leukocytes
– They have purple-staining, U- or kidney-shaped nuclei
– They leave the circulation, enter tissue, and differentiate into
macrophages
 Leukocytes Disorders:
Leukemias
• Leukemia refers to cancerous conditions involving white blood cells
• Leukemias are named according to the abnormal white blood cells
involved
– Myelocytic leukemia – involves myeloblasts
– Lymphocytic leukemia – involves lymphocytes
• Acute leukemia involves blast-type cells and primarily affects children
• Chronic leukemia is more prevalent in older people
 Leukemia
• Immature white blood cells are found in the
bloodstream in all leukemias
• Bone marrow becomes totally occupied with
cancerous leukocytes
• Severe anemia ensues due to excess
production of WBC’s
• The white blood cells produced, though
numerous, are not functional
• Death is caused by internal hemorrhage and
overwhelming infections
• Treatments include irradiation, antileukemic
drugs, and bone marrow transplants
 Platelets

• Platelets are fragments of megakaryocytes

• Their granules contain serotonin, Ca2+,
enzymes, ADP, and platelet-derived
growth factor (PDGF)
• Platelets function in the clotting
mechanism by forming a temporary plug
that helps seal breaks in blood vessels
• Platelets not involved in clotting are kept
inactive by Nitric Oxide (NO) and
prostaglandins
 Human Blood Groups

• RBC membranes have glycoprotein antigens

on their external surfaces
• These antigens are:
– Unique to the individual
– Recognized as foreign if transfused into another
individual
– Promoters of agglutination and are referred to as
agglutinogens
• Presence or absence of these antigens is used
to classify blood groups
 Blood Groups
• Humans have 30 varieties of naturally occurring RBC
antigens
• The antigens of the ABO and Rh blood groups cause vigorous
transfusion reactions when they are improperly transfused
• Other blood groups (M, N, Dufy, Kell, and Lewis) are mainly
used for legalities
 ABO Blood Groups
• The ABO blood groups consists of:
– Two antigens (A and B) on the surface of the RBCs
– Two antibodies in the plasma (anti-A and anti-B)
• An individual with ABO blood may have various types of antigens and
spontaneously preformed antibodies
• Agglutinogens and their corresponding antibodies cannot be mixed
without serious hemolytic reactions
ABO Blood Groups
 Rh Blood Groups

• Presence of the Rh agglutinogens on RBCs is

indicated as Rh+; 85% of population is +
• Lack of antigen indicated as Rh -; 15% of
popn.
• Anti-Rh antibodies are not spontaneously
formed only in Rh– individuals
• However, if an Rh– individual receives Rh+
blood, anti-Rh antibodies form
• A second exposure to Rh+ blood will result in a
typical transfusion reaction
 Transfusion Reactions
• Transfusion reactions occur when mismatched blood is infused
• Donor’s cells are attacked by the recipient’s plasma agglutinins causing:
– Diminished oxygen-carrying capacity
– Clumped cells that impede blood flow
– Ruptured RBCs that release free hemoglobin into the bloodstream
• Circulating hemoglobin precipitates in the kidneys and causes renal
failure
 Blood Typing
• When serum containing anti-A or anti-B agglutinins is added
to blood, agglutination will occur between the agglutinin and
the corresponding agglutinogens
• Positive reactions indicate agglutination
 Blood Typing

Blood type being tested RBC agglutinogens Serum Reaction

Anti-A Anti-B

AB A and B + +

B B – +

A A + –

O None – –
Red Blood Cell Tests
 Red Blood Cell Tests
• Hematocrit (HCT): measures the % of
blood volume taken up by RBC’s
• Mean Corpuscular Volume (MCV):
average volume (size) of RBC’s
• Mean Corpuscular Hemoglobin (MCH):
amt/concentration of hgb in average cell
 Platelets: help stop bleeding by forming
clots. Low plt count: thrombocytopenia
White Blood Cells

• WBC’s are fighter cells

• Some make antibodies
• Some fight directly
• Divided into types by
how they look and what
they do
 WBC Differential
(Different Types of WBC’s)

• 5 types of white blood cells

 neutrophils or polymorphonuclear cells
fight bacterial infections; low count=neutropenia
(HIV,some meds can cause neutropenia)
 lymphocytes: 2 types:
T cells attack + Kill germs/regulate immune system
need to know lymphocyte count to calculate T cells
B cells make antibodies
 More Types of WBC’s

 Monocytes or Macrophages
fight infections by eating germs;high count
usually signifies infection
 Eosinophils
involved with allergies and reaction to
parasites
 Basophils
Seem to be involved in long term allergic
response; not well understood
Blood Chemistry Tests

• Electrolytes:
related to fluid
balance
• Sodium
• Potassium
• Chloride
• Bicarb
 Kidney Function Tests
• Blood Urea Nitrogen
(BUN)
nitrogen in blood
waste that is normally
removed by kidneys
 Creatinine
waste product; most direct
sign of kidney function
 Liver Function Tests

• High enzymes can signal liver damage

(meds, hepatitis, alcohol, drugs)
 ALT (SGPT)
 AST (SGOT)
 Bilirubin yellow fluid produced when RBC’s break down
(liver disease; indinavir and atazanavir can elevate bili)
 Alkaline Phosphatase
 LDH
 Other Tests

• Albumin:
major protein in blood
maintains balance in cells; carries nutrients;can affect other lab
tests

 Erythrocte Sedimentation Rate:

how quickly RBC’s settle in a tube of blood; high sed
rate=inflammation
 Fat in Blood: Lipids

• Fat is a source of energy

• Carries some vitamins
• Helps make hormones
• Helps make cell membranes
• Lubricates some body parts
• Fats are carried wrapped in lipoproteins
• Triglycerides most common, then
cholesterol
So what’s the problem?

• Small lipoproteins
(LDL or VLDL)
carry fat from liver
to rest of body
• Too much of these
cause fat build-up
on walls of arteries
 Lipids

• Cholesterol

• HDL (good cholesterol)

• Ratio

• LDL (bad cholesterol)

• Triglycerides
 Blood Sugar

• Glucose provides energy

• High blood sugar could signal diabetes
• Insulin is produced in pancreas and
helps glucose move from blood to cells
• Some protease inhibitors can cause
elevation of blood sugar by inhibiting
insulin
Types of glucose tests
• Random Blood sugar
(not fasting)
• Fasting Blood sugar
(nothing to eat or drink except H2O for 8
hrs)
• Glucose Tolerance Test
(Starts fasting, then given sweet drink
and measured over time)
• Hemoglobin A1c
(Measures glucose control over 3 month)
 T cell subsets:
It’s a war out there!

• CD4
(cells that HIV targets and kills)

• CD4%
(% of total lymphocytes)

• CD8
(fight HIV)
 Viral Load Tests

• Different types of tests and results

may be different
• PCR
• bDNA (branched DNA)
• Viral load testing measures only
that which is in your blood
• Valuable for managing therapy:
goal is undetectable
Arterial Blood Gas Analysis
 Arterial Blood Gas Analysis (ABG)

• Blood gas analysis, also called arterial blood

gas (ABG) analysis, is a test which measures
the amount of oxygen (O2) and carbon
dioxide ( CO2) in the blood, as well as the
acidity (pH) of the blood.
 Purpose

• An ABG analysis evaluates how effectively the

lungs are delivering oxygen to the blood and
how efficiently they are eliminating carbon
dioxide from it.

• The test also indicates how well the lungs and

kidneys are interacting to maintain normal
blood pH (acid-base balance).
• Blood gas studies are usually done to assess
respiratory disease and other conditions that
may affect the lungs, and to manage patients
receiving oxygen therapy (respiratory
therapy).

• In addition, the acid-base component of the

test provides information on kidney function
too.
 Information provided by an ABG

PaCO2
• This is the partial pressure of carbon dioxide dissolved within the
arterial blood. It is used to assess the effectiveness of ventilation. A
high PaCO2 (respiratory acidosis) indicates underventilation, a
low PaCO2 (respiratory alkalosis) indicates hyper- or
overventilation.
• The normal range for a healthy person is 4.7-6.0 kPa or 35-45
mmHg although in chronic pulmonary diseases it may be
considerably higher and still normal for that patient.
 PaO2
• This is the partial pressure of oxygen
dissolved within the arterial blood and will
determine oxygen binding to haemoglobin
(SaO2). It is of vital importance but is not
used in determining patients' acid base
status and normally low readings indicate
hypoxaemia.The normal range -9.3-13.3
kPa or 80-100 mmHg.
 SaO2
• Oxygen saturation measures how much of
the haemoglobin (Hb) in the red blood cells is
carrying oxygen (O2). Although similar to
SpO2 (measured by a pulse oximeter), it is
more accurate. The normal levels are 97%
and above, although levels above 90% are
often acceptable in critically ill patients.
 pH

• The pH measures hydrogen ions (H+) in

blood. The pH of blood usually between
7.35 to 7.45. A pH of less than 7.0 is called
acid and a pH greater than 7.0 is called
basic (alkaline). So blood is slightly basic.
 HCO3 (Bicarbonate)
• Bicarbonate is a chemical (buffer) that
keeps the pH of blood from becoming too
acidic or too basic & indicates whether a
metabolic problem is present (such as
ketoacidosis). A low HCO3- indicates
metabolic acidosis, a high HCO3- indicates
metabolic alkalosis. HCO3- levels can also
become abnormal when the kidneys are
working to compensate for a respiratory
issue so as to normalize the blood pH.
Normal range - 22–26 mmol/l
 Normal results

• partial pressure of oxygen (PaO2):

80-100 mm Hg
• partial pressure of carbon dioxide (PaCO2):
35-45 mm Hg
• oxygen content (O2CT):
15-23%
• oxygen saturation (SaO2): 94-100%
• bicarbonate (HCO3): 22-26 mEq/L
• pH: 7.35-7.45
 When ABG is ordered?

• Blood gas tests are ordered when you have

symptoms of an O2/CO2 or pH imbalance,
such as difficulty breathing or shortness of
breath & also if you are known to have a
respiratory, metabolic, or kidney disease and
those are experiencing respiratory distress to
evaluate oxygenation and acid/base balance.
• Patients who are “on oxygen” (have
supplemental oxygen) may have their blood
gases measured at intervals to monitor the
effectiveness of treatment.
 After care

• After the blood has been taken, the technician or the

patient applies pressure to the puncture site for 10-15
minutes to stop the bleeding, and then places a dressing
over the puncture.
• The patient should rest quietly while applying the pressure
to the puncture site. Health care workers will observe the
patient for signs of bleeding or circulation problems.