Blood Flow and Viscosity

Blood is a 50:50 suspension of cells in plasma. It is fluid as long as the endothelium is

intact and healthy. Trauma or inflammation of the endothelium, or both activate
haemostatic defence mechanisms. They lead to solid clotting that may increase viscosity,
decrease fluidity or obstruct flow or both. Otherwise, the fluid properties of blood depend on
the haematocrit and the plasma proteome. They determine viscosity.
The hyper-viscosity syndrome is a condition with many causes. The mass of erythrocytes,
and oxygen carrying capacity are normal. However, the increased viscosity and decreased
flow diminishes tissue oxygenation. Consequently, all organ systems are dysfunctional.
The patients are comatose and in renal failure with other clinical disorders in the emergency
setting.
The fluidity and flow properties of blood are essential for the physiological functions in
transport, regulation and body defence mechanisms.
Bulk flow of fluids is driven in one direction by pressure from behind; known as the shear
rate. Resistance to flow is known as viscosity and quantified in centipoise with the use of
viscometers. It is accounted for by the hypothetical laminar structure of fluids that give rise
to shear stress due to friction between the laminae.
The bulk of fluid flowing in one direction is thought to be made of many layers of infinitely
thin layers of fluid known as laminae that flow over each other. Friction between the
laminae is distributed unequally across the diameter of the blood vessel marginating
leukocytes to the side of the blood vessel wall where they come into physical contact with
the endothelium. At the side, they prevent disturbance of laminar flow.
Disturbance of laminar flow results in turbulance and activation of haemostatic mechanisms
via the von willebrand factor (vwf; see later)
Vwf is a biomechanical transducer in haemostasis that shall be explained later.
Viscosity is the ratio of shear stress / shear rate. Water, like plasma, has low viscosity and
flows fast while honey has high viscosity and flows slow.
Blood is a complex or non-newtonian fluid in which flow and viscosity are inversely related.
Taking into consideration the composition of blood, nearly a 50 : 50 suspension of cellular
particles in an acqueous solution, it is amazing that it flows at all and that the viscosity is only
around three times that of water.
Simple or newtonian fluids, such as water, milk and plasma have an intrinsic viscosity that is
independent of other physical parameters such as shear rate or flow rate. Plasma (without
blood cells) is a newtonian fluid.
Blood is known as a complex or non-newtonian fluid because viscosity is inversely
proportional to shear / flow rates.










It can be seen that contrary to
conventional Newtonian fluids in which
viscosity remains constant as shear
increases, Blood is a non-newtonian fluid
because viscosity is inversely proportional
to shear / flow rate






The relatively low viscosity of blood, compared to other suspensions is accounted for by
minimal disturbance of laminar flow brought about by the erythrocytes due to their physical
properties that make them behave as if they were droplets of oil suspended in plasma.
Leukocytes have a disproportionate effect on viscosity because they are nucleated, less
elastic that the erythrocytes and disturb laminar flow.






Laminar Flow

Turbulent Flow
Turbulance occurs when:
the rate of blood flow becomes too high,
the flow passes by an obstruction in a
vessel,
the flow makes a sharp turn,
the flow passes over a rough surface,
the flow may then become turbulent
the viscosity of the blood is decreased
Turbulence results in whorls and eddy
currents that increase resistance resulting in:
Greater effort by the heart
Increased blood pressure
higher risk of atherosclerosis
higher risk of inflammatory reaction
higher risk of thrombosis





Blood behaves as a non-Newtonian fluid because of the behaviour of erythrocytes during
flow. At low shear rates (low force and low velocity), RBCs aggregate, increasing the
resistance to flow (viscosity) of whole blood. As flow increases, the RBC aggregates
dissociate and line up in a more streamlined manner. As flow speeds increase further, RBCs
begin to deform and assume an elongated shape that further decreases resistance to flow.


Factors that Influence Blood Viscosity
Viscosity of blood is determined by TWO mechanisms:
1. THE HAEMATOCRIT AND PROPERTIES OF THE ERYTHROCYTES.
2. THE PLASMA PROTEOME.
The haematocrit also known as the packed cell volume (PCV), is the PROPORTIONAL
VOLUME (%) of red blood cells in blood. Thus the higher the percentage of red blood cells in
the blood, the higher is the viscosity. Viscosity is DECREASED in anemia due to the lower
number of erythrocytes. It is INCREASED in erythrocytosis / Polcythaemia
The tendency of red blood cells to aggregate (the three-dimensional structure of rouleaux
formation) increases the viscosity at low shear rates. Conditions that increase rouleaux
formation include infections, multiple myeloma, inflammatory and connective tissue
disorders, and cancers. It also occurs in diabetes mellitus and is one of the causative factors
for micro-vascular occlusion in diabetic retinopathy.
The internal viscosity of the red blood cell would also influences the blood viscosity as it
effects the capability of the red cell to deform. A reduction in the ability to elastically deform,
increases the blood viscosity. Conditions that increase the internal viscosity (and red cell
membrane elasticity) include dehydration and Sickle cell disease (in both conditions the risk
of vascular occlusion is increased). In the smallest capillaries, in which the circulation
amounts to a column of erythrocytes, the viscosity is determined by the internal viscosity of
the erythrocyte.
2. THE Plasma PROTEIN COMPOSITION AND CONCENTRATION I.E THE PLASMA
PROTEOME HAS CONSIDERABLE EFFECT ON BLOOD VISCOSITY. High molecular
weight proteins such as the IgM pentamers (as in Waldestorms macroglobulinaemia) have a
disproportional effect. Commonly, excessive secretion of Ig light cahins increases plasma
protein concentration and viscosity.

Changes in blood velocity

Velocity of the blood depends mainly on the total cross sectional area of the vessels - being
a closed system, the same amount of blood shall pass through the aorta as through the
capillaries.

Quantification of the erythrocyte sedimentation rate (ESR) is a commonly used
indirect measurement of blood viscosity and a non-specific indicator of disease.
The erythrocyte sedimentation rate (ESR), is the rate at which red blood cells precipitate in a
period of 1 hour. It is a common haematological test which is a non-specific measure of
inflammation.
To perform the test, anticoagulated blood is placed in an upright tube, known as a
Westergren tube, and the rate at which the red blood cells fall is measured and reported in
mm/h.
1, 2, & 3 - Normal
4, 5 & 6 - Accelerated
7 - 'Zero' ESR -
Polycythemia
8 - Very Accelerated ESR
- Multiple myeloma





Erythrocyte aggregation is affected by two major factors:
1. red cell surface charges and

High molecular weight proteins, especially if positively charged, increase
viscosity and favour rouleaux formation increasing ESR
Fibrinogen, the most abundant acute phase reactant, has the greatest effect on the
elevation of ESR.
Paraproteins are positively charged molecules and when abundantly present as in
multiple myeloma increase the ESR to very high levels.

2. frictional forces around the red cell.
A drop in the red cell number, as in anaemia, reduces the friction between the cells
and slightly elevates the ESR;