Blood And Its Clinical Aspects - Dr. Gunjan Barot.pptx

© Dr. Gunjan Barot
GOOD MORNING

© Dr. Gunjan Barot
BLOOD AND
ITS APPLIED
ASPECTS
Presented By: Dr. Gunjan Barot
M.D.S Part 1
Department of Pediatric And Preventive Dentistry
Karnavati School Of Dentistry

 CONTENTS
1. INTRODUCTION
2. BLOOD: PROPERTIES, COMPOSITION,
FUNCTION
3. BLOOD PLASMA
4. HEMOPOIESIS
5. RBC
6. BLOOD INDEX
7. HEMOLYSIS

© Dr. Gunjan Barot
8. HEMOGLOBIN
9. BLOOD GROUPS
10.BLOOD TRANSFUSION
11. WBC'S (NEUTROPHIL, EOSINOPHIL, BASOPHIL,
LYMPHOCYTES, MONOCYTES)
12.PLATELETS
13.HEMOSTASIS
14.BLOOD COAGULATION

© Dr. Gunjan Barot
12.LOCAL HEMOSTATIC AGENTS
13.ANTICOAGULANTS FOR CLINICAL
USE
14.LABORATORY INVESTIGATIONS
• REFERENCES

 INTRODUCTION :
What is Blood?
Blood is circulating tissue composed of fluid plasma & cells
(RBC, WBC, Platelets).
Terms related to blood starts with-haemo/haemato; derived from Greek
word 'haima'
It is connective tissue in fluid form.
Guyton andHall Textbook of medical physiology 12"edition .
Ganong Reviewof Medical Physlology,23th Edition.
Image Source :
https://shusthothaki.com
bloodbank/faq/

© Dr. Gunjan Barot
 PROPERTIES :
• Colour : Red
• Forms 6% to 8% of the total body weight.
• pH : 7.35 – 7.45
• Viscosity : 3 to 5 times viscous than water.
• Specific Gravity : 1.052 to 1.061
• Circulating blood volume will be lesser than total blood volume.
• Average Volume : Males : 4 to 5 litres
Females : 4.5 litres
New Born : 459 ml
Guyton andHall Textbook of medical physiology 12th edition .
Image Source :https://www.istockphoto.com/vector/blood-
drop-running-gm519845735-49824972

 FUNCTIONS OF BLOOD
1. Supply of Oxygen & Nutrients(glucose, Amino acids, Fatty acids)
2. Removal of wastes(CO2, Urea, lactic acid)
3. Immunological functions(circulation WBC's, detection of foreign
materials-by ANTIBODIES)
4. Coagulation- Response to blood vessels
5. Messenger function- Transport of Hormones & Signaling of tissue
damage
6. Regulation of pH & Body Temperature
7. Hydraulic functions
Guylon andHall Textbook of medical physiology 12"edition 2011.
Ganong Reviewof MedicalPhyslology,23th Edition

© Dr. Gunjan Barot
BLOOD PLASMA
When formed elements are removed from blood, a straw coloured liquid called blood plasma
is left. The table below describes the chemical composition of blood plasma
Liquid portion of blood. Acts assolvent and suspending medium for
WATER(91.5%)
components of blood; absorbs, transports and releases heat.
PLASMA
PROTEIN(7.00%)
Exert colloid osmotic pressure, which helps maintain water balance between
blood and tissues and regulatesblood volume.
ALBUMIN
Smallest and most numerous blood plasma proteins; produces by liver.
Transports proteins for several steroid hormones and for fatty acids.
GLOBULINS
Produces by liver and plasma cells, which develop from B lymphocytes.
Antibodies help attack viruses and bacteria. Alpha and beta globulins transport
iron, lipids and fat soluble vitamin.
,,
Guylon
and
Hall
Textbook
of
medical
physiology
12"edition
2011.
Ganong
Review
of
Medical
Physlology,23th
Edition

© Dr. Gunjan Barot
I. Plasma proteins
1. Albumin
2. Globulin
3. Fibrinogen
II. Amino acids
1. Essential amino
acids
2. Non-essential
amino acids
III. Carbohydrate
1. Glucose
IV. Fats
1. Triglycerides
2. Cholesterol
3. Phospholipids
V. Internal
secretions
1. Hormones
VII. Non-protein
nitrogenous
substances
1. Ammonia
2. Creatine
3. Creatinine
4. Xanthine
5. Hypoxanthine
6. Urea
7. Uric acid
VIII. Antibodies
VI. Enzymes
1. Amylaze
2. Carbonic anhydrase
3. Acid phosphatase
4. Alkaline
phosphatase
5. Lipase
6. Esterase
7. Protease
8. Transaminase
1. Sodium
2. Calcium
3. Potassium
4. Magnesium
5. Bicarbonate
6. Chloride
7. Phosphate
8. Iodide
9. Iron
10. Copper
Plasma
Solids: 7%-8% Water: 92%-93% Gases
Organic substances
Inorganic substances
1. Oxygen
2. Carbon dioxide
3. Nitrogen
Guylon
and
Hall
Textbook
of
medical
physiology
12"edition
2011.
Ganong
Review
of
Medical
Physlology,23th
Edition

 COMPONENTS OF PLASMA
• Organic components • Inorganic components
1.]
2.]
3]
4.]
5.]
6.]
Plasma protein
Amino acids
Carbohydrates Fat
Hormones
Enzymes
Antibodies
1. Na
2. Ca
3. K
4. Mg
5. Cl
6. Fe
7. Cu
Guyton andHall Textbook of medical physiology 12"edition .
Ganong Reviewof MedicalPhyslology,23th Edition.

• Haematopoiesis is process of formation of blood cellular
components.
• All cellular components are derived from pluripotent
haemopoietic stem cells.
• In a healthy adult, approximately 1011 to 1012 new blood cells
are produced daily in order to maintain steady state levels in
peripheral circulation.
K sembulingam Essentials of medical physiology 6t h edition
 Haematopoiesis

© Dr. Gunjan Barot
 Haematopoiesis :
Image Source Springuel, Lorraine & Renauld, Jean-Christophe &
Knoops, Laurent. (2015). JAK kinase targeting in hematologic
malignancies: A sinuous pathway from identification of genetic
alterations towards clinical indications. Haematologica. 100.
1240-1253. 10.3324/haematol.2015.132142.

 FACTORS FOR HAEMATOPOIESIS
• Humoral regulation byhormones
• Erythropoietin
• Leucopoietin
• Thrombopoietin
Guyton and Hall Textbook of medical physiology 12"edition .
Guyton and Hall Textbook of medical physiology 12"edition

© Dr. Gunjan Barot
 RED BLOOD CORPUSCLES :
• Also known as Erythrocytes.
• Most abundant cells of blood.
• Transports haemoglobin which in turn carries oxygen to lungs and
tissues.
• Normal Values :
 Male : 5-6 million/mm3
 Female : 4.5 – 5.5 million/ mm3
 Infant : 6-7 million/ mm3
Image Source :
https://www.medscape.com/viewarticle/983646

• Oval biconcave discs & they are flexible.
• Approximately disk diameter- 6.2 to 8.2 micromillimeter
• Lack in cell nucleus-accommodate maximum space for hemoglobin.
Thickness: 2.5 micrometers at the thickest point and 1micrometer or
less in the center.
 The average volume: 85 to 90 cubic micrometers.
MORPHOLOGY OF RED BLOOD CORPUSCLES
Guyton and Hall Textbook of Medical Physiology 12"edition .
GanongReviewof MedicalPhyslology,23th Edition.
Image Source : https://socratic.org/questions/which-
type-of-blood-cells-are-the-most-abundant-in-a-
healthy-human-body

© Dr. Gunjan Barot
 Rouleaux Formation :
 A coin stacking appearance
of the RBC forms because
of the unique discoid shape
of the cells in vertebrates.
 It facilitates the rate of red
cell sedimentation.
 Increased rouleaux
formation in canine blood
smears is associated with an
increase in fibrinogen or
acute phase proteins and is
usually seen
in inflammatory diseases.
Image Source : https://sonographictendencies.com/2016/11/05/rouleaux/

© Dr. Gunjan Barot
Guylon and Hall Textbook of medical physiology 12"edition 2011.
GanongReviewof Medical Physlology,23th Edition.

 FORMATION OF RBCs
-The process is called as Erythropoiesis
Prenatal: 3rd Week-3rdmonth- Yolk sac
3rdMonth-5th Month- Liver
5th Month onwards- RBM
Post- natal: red bone marrow
• Approximately 2.4 million new RBC's are produced per second.
• RBC circulates in body for around 100-120 days.
• Human blood cells take average 20 sec to complete one cycle of
circulation.

• The major function of RBC's is to transport hemoglobin and in turn carries
oxygen from lungs to tissues.
• Red blood cells contains carbonic anhydrase which catalyzes the reaction
between carbon dioxide & water, that has significance in transporting carbon
dioxide from tissues to lungs.
• Blood group determination.
• Excellent acid base buffer.
K sembulingam Essentials of M e d i c a l Physiology 5th Edition
FUNCTIONS OF RBC

A. Variations in count
B. Variations in shape
C. Variations in size
K Sembulingum Essentials of Medical Physiology, 6th Edition
VARIATIONS IN RBC

A. VARIATION IN COUNT
1.] ERYTHROCYTOSIS
Is an increase in circulating rbc's above normal level.
It can be primary & secondary.
• Pathological
1.Primary- Bone marrow
disorder
2.Secondary- Cardiovascular disorder,
respiratory disorder
• Physiological
1. Absolute- high altitude
2. Relative- exercise

2.] ERYTHROPENIA
• It is decrease in RBC's count below normal level
• Deficiency in number of RBC's or decreased level of hemoglobin in
RBC's is called as anemia.
• It may be because of reduced production, lysis of RBC's or blood loss.
• Pathological
1. Primary-bone marrow disorder
2. Secondary- due to any kidney
disease
• Physiological
1. Absolute- reduced production
2. Relative- pregnancy
Harsh Mohan Textbook of Pathology, 6th Edition

B. VARIATIONS IN SHAPE
1. Crenation- hypertonic condition(shrinkage)
2. Spherocytosis- hypotonic condition(globular)
3. Sickle cell- cresentic(sickle cell anemia)
4. Poikilocytosis- unusual shape because of
deformed cell membrane

© Dr. Gunjan Barot
• PATHOLOGIC
SHAPES OF
RED BLOOD
CORPUSCLES
Image Source :
https://labpedia.net//variations-in-red-blood-cell-
morphology/

C. VARIATION IN SIZE
1. Microcytes- (less than 6 µ) iron deficiency anemia, prolonged
forced breathing, increased osmotic pressure.
2. Macrocytes- (8 to 9 µ )megaloblastic anemia, muscular
exercise, decreased osmotic pressure.
3. Megalocytes- (9 to 12 µ) skin disorders
4. Normocytes- (6.2 to 8.2µ)
5. Anisocytes- pernicious anemia

A. PACKED CELL VOLUME (PCV)
B. MEAN CORPUSCULAR VOLUME (MCV)
C. MEAN CORPUSCULAR HEMOGLOBIN (MCH)
D. MEAN CORPUSCULAR HEMOGLOBIN CONCENTRATION
(MCHC)
BLOOD INDICES

© Dr. Gunjan Barot
• It is also known as packed cell volume (PCV) or erythrocyte
volume fraction(EVF) it is volume % of RBC in blood.
• It is normally around 40-48% for men & 36- 42% for
female
HEMATOCRIT
K Sembulingum Essentials of
Medical Physiology, 6th Edition
Image Source :
https://healthlibrary.askapollo.com/hematocrit-test/

 Diagnosis and tx of anemia
 Diagnosis and tx of polycythemia
 Determination and extent of dehydration and recovery from that
 Decision of blood transfusion
• Variation in PCV
Increases in polycythemia and dehydration
Decreases in anemia, and pregnancy
SIGNIFICANCE OF DETERMINING PCV :

© Dr. Gunjan Barot
 MEAN CORPUSCULAR VOLUME (MCV) :
• It is average value of a single red blood cell
and it is expressed in cubic micron.
• Normal mcv is 90 cu micron
• More in pernicious anemia and megaloblastic anemia
• Less in iron deficiency anemia

© Dr. Gunjan Barot
MEAN CORPUSCULAR HEMOGLOBIN
• It is the quantity of hemoglobin present in one red blood cell.
• It is expressed in pico gram (pg) Hb gm/liter of blood X 10
Red cell in million /cu mm
• It decreases in pernicious anemia and megaloblastic anemia

© Dr. Gunjan Barot
MEAN CORPUSCUAR HEMOGLOBIN
CONCENTERATION (MCHC) :
• This is concentration of one red blood cell.
• Expressed in percentage.
• Normal value is 30%
• Increased in iron deficiency anemia

© Dr. Gunjan Barot
Image Reference :
https://wellowise.com/blog/decod
ing-your-blood-report-rbc

© Dr. Gunjan Barot
 HEMOLYSIS OF RBC
• Heme- blood ; lysis- destruction.
• Also known by rupturing of Red Blood Corpuscles and release of
their contents (cytoplasm) into the surrounding fluid. (Ex : Blood
Plasma)
• Hemolysis damage the host cytoplasmic membrane, causing cell
lysis and death.
• Hemolysis can lead to hemoglobinemia due to hemoglobin released
into blood plasma.
• Hemolysis can be invitro or invivo
 Haemolysis
Test

© Dr. Gunjan Barot
 CAUSES :

© Dr. Gunjan Barot
 LIFE SPAN AND FATE OF RBCs :
• Average life
span- about 120
days.
• Spleen- graveyard
of red blood
cells.
• Daily 10% red blood cells, which
are senile, destroyed in
• normal young healthy adults.

• The red, oxygen carrying pigment in rbc is
hemoglobin.
• It consists of protein globin(polypeptide)
united with the pigment haeme(heme).
• Hemoglobin has ability to combine with
oxygen is due to four iron atoms asso. with
each heme group within the molecule.
 HEMOGLOBIN :
 Comprising four subunits,
each having one polypeptide
chain and one heme group

© Dr. Gunjan Barot
 STRUCTURE OF HEMOGLOBIN :
HEME GLOBIN
It is an iron containing porphyrin. It is a protein built from 4
polypeptide chains, two alpha and
two beta chains.
The iron in heme is in ferrous
(fe2+) form.
Of two alpha chains each contains
141 amino acids and of two
beta-chains each contains 146
amino-acids.
Each fe2+ combines loosely and
reversibly with one molecule of
oxygen
K
Sembulingum
Essentials
of
Medical
Physiology,
6th
Edition

© Dr. Gunjan Barot
 FUNCTIONS OF HEMOGLOBIN :
• Transport of oxygen from lungs to the tissues.
• Transport of co2 from the tissues to the lungs.
• It acts as an excellent acid-base buffer, being a protein, it is
responsible for 70% buffering power of whole blood.

© Dr. Gunjan Barot
TYPES OF HEMOGLOBIN:

© Dr. Gunjan Barot
 NORMAL VALUES OF HEMOGLOBIN :

© Dr. Gunjan Barot
 FORMATION OF HEMOGLOBIN
• Synthesis of hemoglobin begins in the pro-erythroblasts and
continues even into the reticulocyte stage of the red blood
cells.
• Therefore, when reticulocytes leave the bone marrow and pass
into the blood stream, they continue to form minute quantities of
hemoglobin for another day or so until they become mature
erythrocytes.

© Dr. Gunjan Barot
 COMPOUNDS OF HEMOGLOBIN :
PHYSIOLOGICAL PATHOLOGICAL
Oxyhemoglobin Methemoglobin
Deoxyhemoglobin Carboxyhemoglobin
Carhemoglobin Sulphemoglobin

© Dr. Gunjan Barot
 ABNORMAL DERIVATIVES OF
HEMOGLOBIN

© Dr. Gunjan Barot
 TREATMENT FOR PATHOLOGICAL
VARIATIONS :
1. For methemoglobin- blood transfusion; but only if small amount
of methemoglobin is present, then an enzyme called
methemoglobin reductase, present on RBC acts on them &
eliminates them.
2. For carboxyhemoglobin- oxygen therapy
3. For sulphemoglobin- generally self limiting; sometimes blood
transfusion needed

© Dr. Gunjan Barot
 DESTRUCTION
OF
HEMOGLOBIN

© Dr. Gunjan Barot
 BLOOD GROUPS :
• DISCOVERED BY THE AUSTRIAN SCIENTIST
KARL LANDSTEINER IN 1901.
• Blood groups are determined by the presence d antigen
in RBC membrane.
• When blood from two individuals is mixed, some
times clumping of RBC's occurs. This clumping is
because of immunological reactions.
KARL LANDSTEINER

© Dr. Gunjan Barot
LANDSTEINER’S LAW :
• If a particular antigen is
present in the RBC's,
corresponding antibody must be
absent in the serum.
• If a particular antigen is absent in
the RBC’s, the corresponding
antibody must be present in the
serum.
• Landsteiner discovered two
blood systems called ABO
system and RHsystem
Image Reference : https://medchrome.com/basic-science/physiology/landsteiners-
law/

© Dr. Gunjan Barot
 ANTIGEN-ANTIBODY PRESENT IN BLOOD GROUPS
IMAGE
RFERENCE
:
https://www.ncbi.nlm.nih.gov/books/NBK2267/

© Dr. Gunjan Barot
 CDE BLOOD GROUP SYSTEM
• Out of C,D and E, D is the strongest antigen.
• Also called rhesus(rh) system
• 85% of the population is - rh+
• If rh-d antigen is present in blood(rbc)
• Rh+
• If rh-d antigen is absent in blood(rbc),
• Rh-
• It is determined by anti-rh serum.

© Dr. Gunjan Barot
 BOMBAY BLOOD GROUP :
• It is also known as (HH) group.
• First discovered in Bombay in 1952.
• Very rare.
• Present in 0.004% of population.
• Named by Dr. Bhande and others.
• Can receive blood only from Bombay blood group people.
 DUFFY BLOOD GROUP :
• Discovered in 1950
• Duffy glycoprotein encoded by FY gene on chromosome 1.
• Duffy glycoprotein is a transmembrane protein.
• It also happens to be a receptor for Plasmodium vivax, a
parasite that invades red blood cells (RBCs) and causes
malaria.

© Dr. Gunjan Barot
 BLOOD TRANSFUSION :
• The process of receiving blood products into one's
circulation intravenously. Transfusions are used in
a variety of medical conditions in order to replace
the lost components of the blood.
• Earlier used whole blood, but modern medical
practice commonly uses only components of the
blood, such as red blood cells, white blood cells,
plasma, clotting factors, and platelets.

• Fresh Blood Transfusion : Blood less than 24 hours old
from the time of collection
• Autologus Transfusion: Blood collected from a patient for
re-transfusion at a later time into the same individual.
• Massive Transfusion : Number of units transfused in a 24
hours period exceeds the recipient’s blood volume.
• Multiple Transfusion : Repeated transfusion of blood over a
long period of time. (months or year)
 TYPES OF BLOOD TRANSFUSION :

© Dr. Gunjan Barot
Image Source : https://www.semanticscholar.org/paper/Management-of-blood-component-preparation-Lin-
Yu/76147016042b206c50438f43f81ed02200277ed3
BLOOD COMPONENT PREPARATION

© Dr. Gunjan Barot
 TYPES OF TRANSFUSION REEACTIONS :
A) Immune mediated hemolytic transfusion reactions:
1. Acute : these are due to preformed antibodies against donor RBC
antigens present in the recipient's blood. Non- ABO incompatibility
reactions due to minor recipient antibodies (anti-rh, anti-kidd or anti-jka)
tend to be milder and generally lead to extravascular hemolysis.
2. Delayed : these are due to an anamnestic response to donor rbc
antigens which produces antibodies after a lag period of 3-1O days. This
requires prior sensitization in the form of pregnancy, transplantation or
transfusions.

© Dr. Gunjan Barot
B. Non immune mediated hemolytic transfusion reactions
These are generally related to improper storage and handling of blood
leading to hemolysis in vitro prior or during transfusion:
1.Thermal injury: during re-warming of the blood if temperatures reach
more than 42°C
2.Cold injury: inappropriate storage with exposure to ice or temperatures
less than 6°C
3. Mechanical injury: lysis during transfusion through small-bore catheters.
4. Infection
5. Concomitant drug-induced hemolysis
6. Concomitant administration of hypotonic solution leading to osmotic
disturbance

© Dr. Gunjan Barot
 RH INCOMPATIBLITY :
• Rh- person cannot receive blood from rh+ person, whereas rh+person can
receive blood from rh-person without any problems.
• If a rh- person receive blood from rh+ person for the first time, due to this
exposure, there will be formation antibodies(anti-rhd)
• So, if a second transfusion is done again with rh+ blood, then, the antibodies
which are already present causes clumping.

© Dr. Gunjan Barot
Image Reference : https://www.britannica.com/science/Rh-blood-group-system

© Dr. Gunjan Barot
 ERYTHROBLASTOSIS FETALIS :
If a rh- mother carry a rh+ fetus, due to placental
barrier the blood doesn't mix. However during delivery
some rh+ from fetus reaches mother.
• So, the mother will start producing antibodies
against rh+, during consecutive pregnancies,
this may cause destruction of rbcs in the fetus
causing hemolytic anemia(erythroblastosis
fetalis).
• So after each pregnancy, the mother will receive
anti-RhD (prophylaxis)to prevent this
incompatibility.

© Dr. Gunjan Barot
 COMPLICATIONS OF BLOOD
TRANSFUSION :
1. Transfusion Reactions : Incompatiblity, Allergic reactions, Sensitizaion to
leucocytes and platelets.
2. Transmission of Diseases : Hepatitis, AIDS, Bacterial Infections
3. Reaction caused by Massive Transfusion : Acid Base Imbalance,
Hyperkalemia, Hypothermia
4. Complication of General I.V Fluid Administration : Thromboembolism, Air
Embolism

© Dr. Gunjan Barot
 WHITE BLOOD CORPUSCLE :
• The WBC's, also called as leucocytes,
are the mobile units of the body's
protective system.
• They are formed partially in the
bone marrow (granulocytes and
monocytes and a few
lymphocytes) and partially in the
lymph tissue (lymphocytes and
plasma cells).

© Dr. Gunjan Barot
• After formation, they are transported in the
blood to different parts of the body
where they are needed.
• The real value of WBCs is that most of them
are specifically transported to the areas of
serious infection and inflammation, thereby
providing a rapid and potent defense against
infectious agents.
Image Source :https://www.fi.edu/heart/white-blood-cells

© Dr. Gunjan Barot
 MORPHOLOGY OF WBC :
• Size: 9-12 µ
• Approximately1% of total blood volume in
healthy adult.
• They Live for around 3-4 days
• Normal Count: 5000-10,000/cubic millimeter
• Infants: 20,000/ cc mm
• Children: 10,000- 15,000/ cc mm
Image Source :https://www.tau.ac.il/medicine/tau-
only/webpath/tutorial/hgb/hgb36.html

© Dr. Gunjan Barot
 FUNCTIONS OF WBC :
• Protects the body against bacteria, virus, parasites and cancerous
cells.
• Removes foreign substances such as toxins and waste products.
• Destroys dead, abnormal and worn out cells.
• Participates in the inflammatory and immune response.

© Dr. Gunjan Barot
Image Source Springuel, Lorraine & Renauld, Jean-Christophe &
Knoops, Laurent. (2015). JAK kinase targeting in hematologic
malignancies: A sinuous pathway from identification of genetic
alterations towards clinical indications. Haematologica. 100.
1240-1253. 10.3324/haematol.2015.132142.

© Dr. Gunjan Barot
Image
Source
:
https://www.sciencefacts.net/types-of-white-blood-cells.html

© Dr. Gunjan Barot
 LIFE SPAN OF WBC :
• NEUTROPHILS : 2-5 DAYS
• EOSINOPHILS: 7-12 DAYS
• BASOPHILS: 12-15 DAYS
• MONOCYTES: 2-5 DAYS
• LYMPHOCYTES: 1 DAYS
 FATE OF WBC :
Image Source : https://www.researchgate.net/figure/Physiological-fate-of-
granulocytes-within-the-blood-pool-The-absence-of-infection-or_fig2_45149217

© Dr. Gunjan Barot
 NEUTROPHILS :
Size - 10-14 microns in diameter
Nucleus:
• Purple in colour
• Multilobed (1-6 lobes), that is
why it is also called polymorphonuclear
leucocyte.
• More the number of lobes, more mature is
the leucocyte.
Cytoplasm :
• Slight bluish in colour
• Granular
Image Source :
https://www.britannica.com/science/neutrophil

© Dr. Gunjan Barot
GRANULES :
i)'Fine' sand like particles:- called 'pinpoints’
(ii)'Neutrophilic' in nature (red-brown in col and
basic stains, therefore, it is called a n
(iii)Also contain varieties of enzymes. The)
substance, the granules are thus regarded
• Important in
inflammatory response
phase and debris.
• First line of defense
• Multi functional cells that attack and destroys viruses
and bacteria..
Image Source : https://epomedicine.com/medical-
students/granular-contents-neutrophils-platelets/

© Dr. Gunjan Barot
 NEUTROPHILIA :
• Means increased in neutrophil count.
Causes are: A) Pathological
1. Acute infections
2. Inflammatory conditions
3. Acute hemolysis
4. Metabolic conditions
5. Poison by insect venom
6. After acute hemorrhage
B)Physiological
1. Exercise
2. Food intake
3. Emotion, stress
Harsh Mohan Textbook of Pathology, 6th Edition
Image Source :
https://imagebank.hematology.org/ima
ge/63834/neutrophilia?type=upload

© Dr. Gunjan Barot
 NEUTROPENIA :
• Decreased count of neutrophils
• Causes-
1. Bone marrow dysfunction
2. Toxins(alcohol, benzene)
3. Immune dysfunction
4. Starvation
5. Medication(antibiotic therapy, chemotherapy, anticonvulsants)
6. Radiation
Image Source :
https://healthlibrary.askapollo.com/neutropenia/

© Dr. Gunjan Barot
Image Source : https://www.brainkart.com/article/Neutrophils-and-Macrophages-Defend-Against-Infections_19501/

© Dr. Gunjan Barot
Image Source : https://www.news-medical.net/life-sciences/What-is-the-difference-Between-a-Phagocyte-Macrophage-Neutrophil-and-Eosinophil.aspx

© Dr. Gunjan Barot
EOSINOPHILS :
• Size: 10-14 microns in diameter.
• NUCLEUS : Purple colour, Usually bilobed, the two lobes are
connected with chromatin thread thus producing 'spectacle' appearance
• CYTOPLASM : acidophilic therefore appears light pink in colour.
• GRANULES : Coarse; stains bright red with acidic dye.
They contain :
Eosinophil peroxidase- Destroys worms
Bacteria and tumor cells
Major basic protein -destroys parasites
Image Source :
https://www.britannica.com/science/eosinophill

© Dr. Gunjan Barot
FUNCTIONS OF EOSINOPHILS :
• Mild phagocytosis because less motile than neutrophils.
• Eosinophils collect at the sites of allergic reactions.
• Eosinophils attack parasites that are too large to be engulfed by phagocytosis.
• Eosinophil granules release chemicals which are toxic to larvae of parasites.

© Dr. Gunjan Barot
• Eosinophilia: i.e. Increase in eosinophils
Causes
Allergic conditions e.g. Bronchial asthma
Parasitic infestation e.g. Worms.
Skin diseases
• Eosinopenia: i.e. Decrease in eosinophils
Seen after injection of corticosteroids
Image Source :
https://healthlibrary.askapollo.com/eosinophils/

© Dr. Gunjan Barot
 BASOPHILS :
-0.5% of the WBCs.
• Important in allergic reactions heparin helps clear fat from blood.
Size:10 -14 microns in diameter Nucleus: as in
eosinophils.
CYTOPLASM: Slight basophilic, therefore, appears blue; granular.
GRANULES : 1.)Coarse, stains purple or blue with basic (methylene blue) dye.
2.)Plenty in number and overcrowd the nucleus resulting in
obscure boundary of the nucleus.
3.)Contain histamine and heparin
Image Source :
https://www.britannica.com/science/baspophils

© Dr. Gunjan Barot
 FUNCTIONS OF BASOPHILS :
• Mild phagocytosis
• Liberates heparin which acts as anticoagulant and keeps the blood
in fluid state in the body.
• Proteases and myeloperoxidase: these enzymes exaggerate
the inflammatory responses.
• Cytokine: IL-4 accelerates inflammatory response

© Dr. Gunjan Barot
Basophilia: i.e. Increase in basophils.
Causes
Chickenpox Smallpox
Tuberculosis Influenza
Basopenia: i.e. Decrease in basophils.
Causes
After administration of
glucocorticoids. Drug induced
reactions.
K Sembulingum Essentials of Medical Physiology, 6th Edition Image Source :
https://healthlibrary.askapollo.com/basophils/

© Dr. Gunjan Barot
 LYMPHOCYTES :
- 25-33 % of the WBCs
B-lymphocytes: produce antibodies
T-lymphocytes:
Directly destroy virus- invaded cells and cancer cells
Types of Lymphocytes
Large lymphocytes:10-14 microns in diameter: precursor of small lymphocytes.
Small lymphocytes : 7-1O microns in diameter; responsible for antibody production
Image Source :
https://www.britannica.com/science/lymphocyte

© Dr. Gunjan Barot
NUCLEUS :
• Single; Large; Purple in colour.
• Shape: round, oval or indented.
• Central in position and occupies whole of the cell leaving marginal cytoplasm at one end of it
or all around it.
• Nuclear chromatin is coarse and lumpy(shapeless).
CYTOPLASM :
• Pale Blue
• Scanty, its amount is always less than the amount of the nucleus
FUNCTIONS:
Produce antibodies, immune substances, specially in delayed hypersensitivity.

© Dr. Gunjan Barot
• Lymphocytosis i.e. Increase in lymphocytes.
Causes :
-In children lymphocytes (60%) are more than neutrophils (40%), called relative lymphocytosis.
• Chronic Infections : Ex. Tuberculosis(TB).
• Lymphatic leukaemia.
• Viral infections.
K Sembulingum Essentials of Medical Physiology, 6th Edition Images Source : https://healthlibrary.askapollo.com/lymphocytosis/

© Dr. Gunjan Barot
Lymphopenia i.e. Decrease in lymphocytes.
Causes :
• Hypoplastic bone marrow AIDS
• Lupus
• Idiopathic CD4+ Lymphocytopenia
Image Source : https://www.ncbi.nlm.nih.gov/books/NBK549819/

© Dr. Gunjan Barot
 MONOCYTES :
-2-6 % of the WBCs.
• Exit blood (diapedesis)
• To become macrophages
• Phagocytic = defends against viruses and bacteria
• Size: 10-18 microns in diameter with irregular cell outline.
Nucleus: Single, pale staining.
Round or indented (kidney shaped).
Eccentric in position i.e. Present on one side of the cell.
Nuclear chromatin is finely reticular.
Cytoplasm: usually pale blue; clear.
Image Source :
https://www.verywellhealth.com/what-are-
monocytes-2252110

© Dr. Gunjan Barot
Monocytosis: increase in monocytes
Causes : Tuberculosis Syphilis
Some leukemias.
Monocytopenia:decrease in monocytes.
Cause: Hypoplastic bone marrow.
K Sembulingum Essentials of Medical Physiology, 6th Edition Images Source : https://healthlibrary.askapollo.com/monocytes/

© Dr. Gunjan Barot
 PLATELETS AND THROMBOCYTES
• Platelets are cellular fragments derived from the cytoplasm
of megakeratocytes.
• They do not contain a nucleus.
• Have mitochondria and various cytoplasmic granules
• Do not possess even a golgi body or rough endoplasmic
reticulum.
• 1-4 micron in diameter and is smallest of all the blood
cells.
• Each megakeratocyte produces between 1,000 to 3,000
platelets during its lifetime.

© Dr. Gunjan Barot
 FORMATION OF
PLATELETS :

© Dr. Gunjan Barot
https://doi.org/10.1016/j.blre.2004.05.002.
K
Sembulingum
Essentials
of
Medical
Physiology,
6th
Editio

© Dr. Gunjan Barot
• The circulating platelets represent approx. 60-75% of the platelet pool of
the body, the remaining are mostly in the spleen. Therefore, spleen acts as a
reservoir of platelets.
• Life span: 8-12 days.
• Destruction: mainly in the spleen. In hypersplenism(overactivity of
spleen), the platelets may almost disappear from circulation
• Normal count is 1.5 to 4 lacs/ cu mm (average: 2.59 lacs/cu mm). Its
count is very much constant.

© Dr. Gunjan Barot
THROMBOCYTOSIS :i.e. Increase in platelet count.
Causes:
• After administration of epinephrine due to splenic contraction. After
trauma e.g. Surgery, injury, child birth etc.
• Splenectomy (removal of spleen)
• Stress - causes increased epinephrine release resulting in spleen contraction.
• Hemorrhage Allergic condition
Image
Source
:
https://www.britanicaa.com/search/thrombocytosis

© Dr. Gunjan Barot
THROMBOCYTOPENIA: i.e. decrease in platelet count.
Causes:
• Bone marrow depression.
• Splenomegaly
• Viral infection e.g. Dengue fever (particularly attacks platelets).
Aplastic and pernicious anemia
• Acute infections
Typhoid
• Tuberculosis
K Sembulingum Essentials of Medical Physiology, 6th Edition Image Source :
https://www.britanicca.com/search/thrombocytopenia

© Dr. Gunjan Barot
 INACTIVE PLATELETS AT
RESTING PHASE
 PLATELETS AT THE
BEGINNING OF ACTIVATION
PHASE
Image Source : Rozman, Primoz & Semenič, Danijela & Smrke, Dragica. (2011). The Role of Platelet Gel in Regenerative Medicine. 10.5772/26130.
SCANING ELECTRON MICROSCOPE IMAGE

© Dr. Gunjan Barot
 PATHOLOGIES OF BLOOD PLATELETS :
a)Purpura: purplish discoloration of the skin and mucous membranes due
to the spontaneous extravasation of blood and it self as a symptoms rather
then a disease entity.
Nonthrombocytopenic purpura
Thrombocytopenic purpura
1. Primary
2. Secondary
b) Thrombocythemia: Increase in the number of circulating blood platelets.
c) Thrombosis: Formation of blood clot inside blood vessels - obstruct the blood
flow.
Image Source :
https://images.app.goo.gl/q3ThPt
uYuPH1y2tz7
• Idiopathic
Thrombocytopenic
Purpura

© Dr. Gunjan Barot
d) Von Willebrand disease: Is the most common in humans.
An acquired form can sometimes result from other medical conditions. It arises from a
deficiency in the quality or quantity of Von Willebrand factor(vwf).
e) Aplastic Anemia: Is a rare disease in which the bone marrow and the hemopoietic
stem cells that reside are damaged.
Images Source : The Ohio State University : https://cancer.osu.edu/for-patients-and-caregivers/learn-about-cancers-and-treatments/cancers-conditions-and-treatment/benign-blood-
diseases/von-willebrand-disease
Von
Willebrand
Disease
Aplastic
Anemia

© Dr. Gunjan Barot
 Haemostasis :

© Dr. Gunjan Barot
 EVENTS IN HAEMOTASIS
A. VASCULAR CONSTRICTION
B. FORMATION OF A PLATELET
PLUG
C. FORMATION OF A BLOOD CLOT
D. EVENTUALGROWTH OF
FIBROUS TISSUE
Image Source : https://study.com/academy/lesson/hemostasis-coagulation-process-platelet-formation-clotting-
conditions.html

© Dr. Gunjan Barot
A. VASCULAR CONSTRICTION
(1) Local myogenic spasm
(2) Local autacoid factors from the
traumatized
tissues and blood platelets
(3) Nervous reflexes.
Image Source :http://europepmc.org/article/MED/29340130

© Dr. Gunjan Barot
B. FORMATION OF PLATELET PLUG
• When platelets come in contact with a damaged vascular surface, change their shape.
• They begin to swell; they assume irregular forms
• With numerous irradiating pseudopods protruding from their surfaces.
Their contractile proteins contract forcefully and cause the release of granules that contain
multiple active factors; they become sticky so that they adhere to collagen in the tissues and
the protein
• Called von Willebrand factor that leaks into the traumatized tissue from the plasma.

© Dr. Gunjan Barot
Image
Source
:
https://link.springer.com/article/10.1007/s10237-019-01262-x

© Dr. Gunjan Barot
C. FORMATION OF BLOOD CLOT
• It is a process by which blood changes from liquid to gel forming a blood clot.
• The mechanism of clotting involves : activation, adhesion and aggregation of platelets
along with deposition and maturation of fibres.
D. EVENTUAL GROWTH OF TISSUE
• into the blood clot to close the opening in blood vessel permanently

© Dr. Gunjan Barot
 BLOOD COAGULATION :
• The clot begins to develop in 15 to 20 seconds of the trauma to the vascular wall has
been severe, and in 1 to 2 minutes if the traumahasbeen minor.
• Activator substances from the traumatized vascular wall, from platelets, and from blood
proteins adhering to the traumatized vascular wall initiatethe clotting process.
Image
Sources
:https://jackwestin.com/resources/mcat-content/circulatory-
system/coagulation-clotting-mechanisms

© Dr. Gunjan Barot
 MECHANISM OF BLOOD COAGULATION
• More than 50 important substances that cause or
affect blood coagulation have been found in the
blood and in the tissues.
Some that promote coagulation are called
procoagulants, and others that inhibit
coagulation are called anticoagulants.

© Dr. Gunjan Barot
Image Source : http://www.medicinehack.com/2011/05/clotting-factors.html

© Dr. Gunjan Barot
• Prothrombin activator is generally considered to be formed in two ways:
1. By the extrinsic
Pathway that begins with trauma to the vascular wall and surrounding tissues.
2. By the intrinsic
Pathway that begins in the blood itself
Image Source :

© Dr. Gunjan Barot
 INTRINSIC AND EXTRINSIC PATHWAY
• After blood vessels rupture clotting occurs by both pathways.
• Extrinsic pathway can be explosive, once initiated clotting can
occur in as little as 15 seconds.
• Intrinsic pathway is much slower to proceed usually
requiring 1 to 6 minutes to cause clotting.
• Within a few minutes after a clot is formed, it begins to
contract and usually expresses most of the fluid from
the clot within 20 to 60 minutes

© Dr. Gunjan Barot
 CLOTTING CASCADE :
Image
Source
:
https://epomedicine.com/medical-students/simple-coagulation-cascade

© Dr. Gunjan Barot
 FIBRINOLYSIS :
• Lysis of blood clot inside the blood vessel is
called fibrinolysis.
• This occurs by a substance called
fibrinolysin /plasmin
• Significance- Allows reopening of affected
blood vessels and prevents development of
infarction.

© Dr. Gunjan Barot
CONDTIONS CAUSING EXCESSIVE
BLEEDING IN HUMANS :
• Vitamin k deficiency
• Von Willebrand's disease
• Para haemophilia
• Hypofibrinogenemia
• Fibrin-stabilizing factor deficiency
• Thrombocytopenia
• Haemophilia

© Dr. Gunjan Barot
 LOCAL HEMOSTATIC MEASURES :
A.] MECHAICAL METHODS
• Pressure
• Use of Hemostats
• Suture and Ligation
B.] CHEMICAL METHODS
• Gelfoam
• Oxygel
• Thrombin
• Fibrin Glue
• Adrenaline
C.] THERMAL AGENTS :
• Cautery
• Cryosurgery
• Electrosurgery
D.] SYSTEMIC AGENTS
• Whole Blood
• Fresh Frozen Plasma
• Cryoprecipitate

© Dr. Gunjan Barot
 GELFOAM
• Gelfoam is one of commonly employed agents for the control of minor bleeding.
• Porous, pliable sponge made from dried and sterilized porcine skin gelatin.
• Related to formation of a mechanical matrix that facilitates clotting rather than
affecting the blood-clotting mechanism.
• Reported adverse reactions are : Giant cell granuloma
Hematoma formation
Foreign body reactions
Excessive fibrosis
Toxic shock syndrome
Failure of absorption.
•
Kumar
MP;
Local
Hemostatic
Agents
In
The
Management
Of
Bleeding
In
Oral
Surgery
:
Asian
Journal
Of
Pharmaceutical
And
Clinical
Research
Volume
9
Issue
3

© Dr. Gunjan Barot
20 Pieces: Rs. 1370/-
Company : Coltene
Box of 2 Pieces 80x50x10 mm each approx.
Rs. 320/-
Company : Sri Gopal Krishna Lab Pvt Ltd;
Mumbai

© Dr. Gunjan Barot
 BONE WAX
• Bone wax is a sterile mixture of beeswax, paraffin, and isopropyl palmitate (a
softening agent) that is packaged in individual foil envelopes.
• It is useful when bleeding is from a visualized local vascular channel within bone,
commonly referred to as a "bone bleeder," at the surgical site.
• Bone wax is non resorbable, and due to its possible adverse effect on osteogenesis,
caution should be used where regeneration of bone is expected (eg, a future
implant site).
• Mild inflammatory reactions have been reported in tissues adjacent to the site of
bone wax implantation, and this agent may prevent the clearing of bacteria from
infected sites.
Kumar MP; Local Hemostatic Agents In The Management Of Bleeding In Oral Surgery : Asian Journal Of Pharmaceutical And Clinical Research Volume 9 Issue 3

© Dr. Gunjan Barot
Company : Ethicon
Pack Of 12 : 2.5 grams
Rs. 1400/-
Company : Unisur Pvt Ltd.
2.5-gram foil envelopes with
sealed overwrap
Rs. : 1000/-

© Dr. Gunjan Barot
 COLLAGEN BASED PRODUCTS
• Derived from either bovine tendon Or bovine dermal collagen and are non-toxic and
non-pyrogenic and to control capillary, venous, and small arterial bleeding.
• It should Not be used
(1) in closed spaces because of swelling
(2) on bony defects(Fractures) as it may interfere with bone regeneration, and for Control
of hemorrhage from large arteries.

© Dr. Gunjan Barot
Adverse reactions include:
(1) encapsulation of fluid and foreign body reaction, if the
product Is left in the wound, stenosis of vascular structures
if cellulose is used to wrap a vessel tightly.
(2) burning sensation when placed in unanesthetized nasal
passages.
(3) Excessive amounts of the material should be removed if
possible to prevent delayed healing,
(4) surgical Granulomas
(5) neurological complications.
Santosh Kumar MP; Local Hemostatic Agents In The Management Of Bleeding In Oral Surgery : Asian Journal Of Pharmaceutical And Clinical Research Volume 9
Issue 3

© Dr. Gunjan Barot
 ABSORBABLE HEMOSTAT COLLAGEN SPONGE
• Collagen derived from purified and lyophilized (i.e. Freeze-dried) Bovine flexor tendon
and is available as soft, white, pliable, non-friable, coherent, sponge-like structures.
• Products are highly absorbent and able to hold many times their own weight of fluid.
• Held in place for approximately 2-5 minutes to achieve hemostasis and then may be
removed, replaced, or left in situ.
• In addition to serving as a mechanical obstruction to bleeding, these materials affect
the coagulation process.
• The aggregated platelets degranulate, releasing factors such as thromboxane A2 that
assist in the formation of a clot.

© Dr. Gunjan Barot
Company : Ethicon
12 Hemostats Per Box
Rs. 950/-
Company : Aegis Life Sciences
12 Hemostats Per Box
Rs. 400/-

© Dr. Gunjan Barot
 ACTCEL
• New topical hemostatic agent made from treated and sterilized cellulose, available as
meshwork-like surgicel.
• On contact with blood, it expands 3-4 times its original size and gets converted into gel.
• It dissolves completely in 1-2 weeks into biodegradable end products Glucose and water and
does not affect wound healing.
• Actcel's mechanisms of action are multiple, enhancing the coagulation process biochemically
by enhancing platelet aggregation and physically by 3D clot stabilization.
• It is used in third molar sites and supposed to prevent dry sockets. Furthermore, it is used in
periodontal and orthognathic surgeries.

© Dr. Gunjan Barot
 FlBRIN SEALANTS
• Natural or synthetic combination hemostatic agent and also tissue adhesive which has an
impact on angiogenesis and wound healing.
• These products can be applied using a syringe-like applicator or sprayed over a larger area
using a gas driven device.
• It can be used in bone grafting procedures particularly sinus lift surgery.
• It is contraindicated in patients who are sensitive to bovine proteins.
• An excessively thick sealant layer may prevent revascularization at the surgical site, causing
tissue necrosis.

© Dr. Gunjan Barot
 ALUMINUM DERIVED HEMOSTAT
(BIOGLUE)
• Tissue adhesives have been used widely for
decades, for both : Hemostatic and sealant
properties.
• The main disadvantage of bioglue is that it
can leak through suture tracks.

© Dr. Gunjan Barot
 CHITOSAN BASED PRODUCTS
• Chitosan is a naturally occurring, Biocompatible, electro-positively charged
polysaccharide that is derived from shrimp shell chitin.
• This charge attracts the negatively charged red blood cells forming an
extremely viscous clot, which seals the wound and causes hemostasis.
• Chitosan enhances hemostasis by interacting with cellular components
forming a cellular lattice that entraps cells to form an artificial clot.

© Dr. Gunjan Barot
 THROMBIN
• Thrombin may be used topically as a dry powder, as a solution for use with gelatin
sponges, mixed with a gelatin matrix, or as a spray. It has a rapid onset of action (e.g.,
Within 1O minutes).
• It converts fibrinogen to fibrin. It is commonly used with Gelfoam to treat moderate to
severe bleeding.
• Thrombin should never be injected into the bloodstream or allowed to enter the
bloodstream through large, open blood vessels because it can cause extensive
intravascular clotting which can be fatal.

© Dr. Gunjan Barot
 TRANEXAMIC ACID
• Tranexamic acid is an antifibrinolytic agent that stabilizes clots and facilitates clot
formation by competitively inhibiting plasminogen, the enzyme responsible for activating
plasmin.
• The main role of plasmin in the body is clot degradation or fibrinolysis; hence,
Tranexamic acid non competitively inhibits plasmin and stabilizes clot formation.
• Oral tranexamic acid has been shown to be beneficial in the management of patients with
both inherited and acquired bleeding diseases undergoing minor oral surgeries.
• It can also be useful as a prophylactic mouthwash in patients who are on anticoagulant
medications which require oral surgery.
Kumar MP; Local Hemostatic Agents In The Management Of Bleeding In Oral Surgery : Asian Journal Of Pharmaceutical And Clinical ResearchVolume 9 Issue 3

© Dr. Gunjan Barot
Ankaferd Blood Stopper is a medical product used
to stop minor and major bleeding after
extracorporeal injuries, traumatic cuts, dental
operations, spontaneous or surgical interventions.
It is the first Turkish product licensed by the
Ministry of Health.
Types : Absorbable wet tampon
Wet bumper
Push & stop Bumper
Spray and Ampoule

© Dr. Gunjan Barot
 HEMOSTATIC SOLUTIONS
• Styptics
Styptics, e.g., Aluminum solutions when applied locally cause hemostasis by
contracting tissue to seal injured blood vessels.
• Tannie acid
Tannie acid is a commercial compound that is similar to the plant Polyphenol
tannin, which stops bleeding from mucous membrane via Vasoconstriction.
• Lysine analogs
Tranexamic acid, epsilon-aminocaproic acid
Santosh Kumar MP; Local Hemostatic Agents In The Management Of Bleeding In Oral Surgery : Asian Journal Of Pharmaceutical And Clinical Research Volume 9
Issue 3

© Dr. Gunjan Barot
 ANTICOAGULANTS FOR CLINICAL USE :
1. Heparin: as intravenous anticoagulant
• Relatively small quantity injected: 0.5-1 mg/kg of weight( increases blood clotting time by
6-30 minutes
• The action of heparin lasts about 1.5 to 4 hours. The injected heparin is destroyed by an
enzyme in the blood known as heparinase.
2. Coumarins: When a coumarin, such as warfarin, is given to a patient, the plasma levels of
prothrombin and factors VII, IX, and X, all formed by the liver, begin to fall, indicating that
warfarin has a potent depressant effect on liver formation of these compounds.
Warfarin causes this effect by competing with vitamin k.
Normal coagulation usually returns 1 to 3 days after discontinuing coumarin therapy.

© Dr. Gunjan Barot
 LABORATORY INVESTIGATIONS :
1) BLEEDING TIME (BT)
2) CLOTTING TIME (CT)
3) PROTHROMBIN TIME (PT)
4) PARTIAL THROMBOPLASTIN
TIME (PTT)
5) THROMBIN TIME (TT)

© Dr. Gunjan Barot
 BLEEDING TIME :
Provides assessment of platelet count and function.
Normal value : 3-6 Minutes
Prolonged Bleeding Time :-Congenital and acquired disorder Of Platelet function
-Thrombocytopenia
-Purpura
-Von Willebrand Disease

© Dr. Gunjan Barot
 Dukes method: with the duke method, the patient spricked with a
special needle or lancet, preferably on the earlobe or finger tip after having
been swabbed with alcohol. The prick is about 3-4 mm deep. The patient
then wipes the blood every 30 seconds with a filter paper.
The test ceases when bleeding ceases.

© Dr. Gunjan Barot
 CLOTTING TIME :
• NORMAL VALUE: 4-9 MIN
• PROLONGED CLOTTING TIME: HEMOPHILIA A WITH VASCUAR
DEFORMITY
• METHOD: CAPILLARY GLASS METHOD

© Dr. Gunjan Barot
PROTHROMBIN TIME :
• Measures effevtiveness of extrinsic pathway.
• Prolonged prothrombin time : Vitamin K Deficiency
• Normal Value : 12-15 Seconds
• Measures effevtiveness of extrinsic pathway.
• Prolonged prothrombin time : Vitamin K Deficiency
• Normal Value : 12-15 Seconds
• Prothrombin time is commonly measured using blood plasma.
• Blood is drawn into a test tube containing liquid citrate.
• Blood is mixed & then centrifuged to separate blood cells from
plasma.
• Tissue factor- thrmboplastin is then added and clotting time is
checked.

© Dr. Gunjan Barot
PARTIAL PROTHROMBIN TIME :
• Measures effectiveness of intrinsic pathway & measures
coagulation disorders
• Normal value: 25-40 seconds
• Prolonged PTT- Factor Ill deficiency
Increases in hemophilia
Anticoagulation with heparin

© Dr. Gunjan Barot
 METHOD :
• Blood samples are collected in tubes with oxates or citrate to arrest
coagulation by binding to calcium. In order to activate the intrinsic
pathway, phospholipid and activator (such as kaolin, ellagic acid and
calcium to reverse the anticoagulant effect of oxalate) are mixed into
the plasma sample.
• The time is measured until a thrombus (clot) forms.

© Dr. Gunjan Barot
 THROMBIN TIME :
• It measures the rate of conversion of fibrinogen to fibrin
• Normal value: 9-13 seconds
• Prolonged TT- contamination with heparin or acquired liver diseases
• Method-
 After liberating the plasma from the whole blood by
centrifugation, bovine thrombin is added to the sample of
plasma.
 The clot is formed and is detected optically or
mechanically by a coagulation instrument.
 The time between the addition of thrombin and the clot
formation is recorded as the thrombin clotting time

© Dr. Gunjan Barot
 INR : International Normalized Ratio
• The International Normalized Ratio (INR) is a laboratory measurement of how long
it takes blood to form a clot.
• It is used to determine the effects of oral anticoagulants on the clotting system.
• It is the ratio of Patient’s Prothrombin time to that of the normal Prothrombin time.
INR = Patient’s PT
Normal PT

© Dr. Gunjan Barot
• It should be noted that INR is used to monitor Anticoagulant Therapy and
NOT to be used as a coagulation screening test.
• INR values of 5.0 or greater indicates a serious risk of spontaneous bleeding
episodes.
• NORMAL RANGE : 0.8 - 1.2 (No Anticoagulation Therapy)
2 - 3 (On Anticoagulation Therapy)
INR Allowable Procedures
INR < 3 Infiltration Anesthesia, Scaling &
Root Planing
INR < 2 Block Anesthesia, Minor Surgery,
Extractions
INR <1.5 Major Surgery

© Dr. Gunjan Barot
• The guidelines of American College Of Chest Physicians (ACCP) recommends dental
surgery without Vitamin K Antagonists (VKA) Interruption with the use of a pro
hemostatic agent.
• The interruption of VKA treatment before dental procedures is not recommended for
interventions that are unlikely to cause bleeding for low and high bleeding risk
procedures if the INR of the patient <3.5 , 24 hours before the planned innervation.
• If INR >3.5 then the procedure should be delayed until the INR Values has been
reduced till <3.5
Antitrombotic Therapy And Preventive Thrombosis; 9th edition American College of Chest Physicians, Evidence Based Clinical Practice
Guidelines.

© Dr. Gunjan Barot
 FASTING PLASMA GLUCOSE :
(FPS)
- Fasting blood sugar
- Not to eat and drink anything (except water) atleast
for 8 hours before the test.
Result Fasting Blood Glucose
Normal Less than 100mg/dl
Pre Diabetes 100 mg/dl to 125 mg/dl
Diabetes Mellitus >125 mg/dl
Reference : American Diabetes Association

© Dr. Gunjan Barot
Barrio, Maria & David, Florent & Hughes, Lynne & Clifford, David & Wilderjans, Hans & Bennett, Rachel. (2018). A retrospective
report (2003–2013) of the complications associated with the use of a one-man (head and tail) rope recovery system in horses
following general anaesthesia. Irish Veterinary Journal. 71. 10.1186/s13620-018-0117-1.

© Dr. Gunjan Barot
Recommendations for doing FBS :
Routine preoperative testing in adults undergoing elective non cardiothoracic surgery, Joan Vlyaen et al, KCE
Report 280

© Dr. Gunjan Barot
 HbA1C (Glycated Hemoglobin Test)
• Determines how well is an individual maintaining the diabetes.
• Glucose enters the red blood cells and links up (glycates) with molecules of
hemoglobin.
• HbA1C reflects average plasma glucose of past 12 weeks.
Result HbA1C
Normal < 5.7%
Pre Diabetes 5.7% to 6.5%
Diabetes Mellitus > 6.5%
Reference : American Diabetes Association

© Dr. Gunjan Barot
 Test For Drug Allergy
Mantoux test: The Mantoux test or Mendel-Mantoux
test (also known as the Mantoux screening test, tuberculin
sensitivity test, or Purified protein derivative (PPD)
test for purified protein derivative) is a screening test
for tuberculosis (TB) and for tuberculosis diagnosis. It is
one of the major tuberculin skin tests used around the
world, largely replacing multiple-puncture tests such as
the tine test.
Report 280

© Dr. Gunjan Barot
 HIV
• Enzyme linked immunosorbent assay (ELISA) – A screening test.
• Western Blot – Used for confirming presence of HIV antibody.
• Positive : AIDS, AIDS related complex
 HBsAg
• Hepatitis B Virus
• As it can be spread via blood
Report 280

© Dr. Gunjan Barot
Conclusion :
• Preoperative laboratory test should be ordered based on
defined indications such as positive findings on a history
and physical examination.
• A thorough history and physical examination can be used to
identify those medical conditions that might affect
perioperative management and direct further laboratory
testing.

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