What would cause Hgb to plummet? - page 2

I had a patient last week I can't stop thinking about. Med-surg floor, 40 yr old female, admitted with SOB and fevers one week s/p a Thymectomy to treat myasthenia gravis. After the surgery she had... Read More

  1. Visit  squatmunkie_RN profile page
    3
    I'm going to go with a pneumothorax or hemithorax. Possible sepsis. Please let us know, im curious now! And the lung issue could've been too small to show up on the 1st cxr. We need the results of the CT.

    I think you did everything right. The doc probably should've investigated the cause of the 7.9 hgb and sob when you 1st called not wait until later in the day to do a recheck
  2. Visit  Anna Flaxis profile page
    3
    I vote hemothorax as well. Yes, that would show up on a CXR, and I'm sort of surprised a stat portable CXR wasn't done. What did the chest CT show?
    citylights89, tewdles, and nrsang97 like this.
  3. Visit  tewdles profile page
    3
    My opinion is that she was bleeding into her chest when you took over her care.
    The "lung spasms" were likely a physical symptom of the process, discomfort.
    I agree that a stat CXR was justified.
    prmenrs, Esme12, and nrsang97 like this.
  4. Visit  Esme12 profile page
    1
    Quote from Hygiene Queen
    So, you mean an O2 sat isn't measuring the number of trucks, but how much (hgb) any of the available trucks are carrying...
    Now, see, I like that example you used.
    That's great visual.
    But....... those trucks were carrying/delivering gasoline.....and you have less trucks......therefore, you have less gasoline arriving at their destination.

    Now think where the thymus gland is........


    What complications can arise from a surgery that involves the chest? Did this patient have a chest incision? or was it done with a scope?

    The patient had a bleed somewhere......that "feeling" in the right side of her chest.....and indicator that there is a BIG problem....in the lung which was already indicated with the large chest tube output from the other side of the chest.
    Last edit by Esme12 on Nov 18, '12
    anotherone likes this.
  5. Visit  Esme12 profile page
    4
    Quote from AlphaPig
    I had a patient last week I can't stop thinking about. Med-surg floor, 40 yr old female, admitted with SOB and fevers one week s/p a Thymectomy to treat myasthenia gravis. After the surgery she had had some complications and ended up having to have a left thoracentesis to remove 850cc fluid. Then, she went home for a few days before being readmitted with the SOB and fevers.

    The day I had her (about 3 days after readmit), she looked a little pale and lethargic in the morning and was c/o right lung spasms when she breathed. Vitals normal, afebrile, O2 sat 97% on 3L NC. Pt slightly SOB, lungs diminished, but otherwise fine. However, Hgb was 7.9. Two days before it had been over 9. I called the MD and he ordered a CBC to be drawn later that afternoon to recheck it.

    I gave the pt some IV dilaudid to help with the pain of the lung spasms, and besides being a little SOB, pt fine.

    At 2:00, I draw the CBC and notice pt looking a little more pale with a slight bluish tinge to lips. Pt O2 sat 90% on 3L. Bump it to 4, call respiratory for a treatment and take the CBC to lab. 20 minutes later lab calls me to report Hgb of 5.9!

    Called the MD with the results (who was just as surprised as I was) and he ordered some tests, 2 units blood, etc.

    Go into room and find patient extremely SOB, anxious, bluish lips, pale, O2 sat 88% on the 4L. Bump the O2 to 6L and called a rapid response.

    Pt ended up being transferred to the unit.

    My question - where on earth was this lady bleeding?? No apparent GI bleed, pt's abdomen soft and flat, pt had just had a lung xray that morning that was unchanged from the previous days xray (moderate pleural effusions). I've never seen a Hgb drop that fast. I am relatively new and want to know if I am missing something obvious (if I am, please don't be mean to me, I want to learn)

    Also, I don't know if this is related at all, but when I drew patient's lab, her blood was SO THICK and dark, it was like trying to get chocolate pudding out of her veins.

    Thoughts?
    This is to show you what to look for. How my thought process works.Bleeding easily causes a drop like that. Things that would stick out to me.....that this patient had a chest surgery....sternotomy. She has a history of having 850cc's of fluid removed from the opposite lung ( it would help you to find out what the fluid looked like). Thymectomy patients can have complications for several weeks post surgery.

    Now this patient is having specific "lung spasms" appears pale....I better keep an eye on her. I draw the labs at 2PM and I am alarmed that this patient is looking blue with circumoral pallor....and her sat is poor.....I bump her O2 to 6lpm and call resp to place patient on 100% O2.....I beg lab for an extra extra double fast H/H and have resp do abg's (especially if their machine gives a hGb) and I make sure lab has the blood READY ASAP! I probably would have called the RR now because this patient is actively deteriorating........

    You did a good job....I personally would be a little more aggressive with the O2 and the "lung spasms would alarm me......well done!
    MinnieMomRN, JulieL, tewdles, and 1 other like this.
  6. Visit  psu_213 profile page
    6
    Quote from Bec7074
    First of all, low sats are not related to low hgb. This is a big misconception in nursing. I had a doc explain it to me once (cuz I too used to get confused). Low hgb is having less trucks on the highway but they can still carry the same load. Sats (% of oxy on hgb) is the load.
    It is true that low hgb does not cause low sats, however low hgb can mean tissue hypoxia even in the setting of "normal" sats. If hgb is low that means there is less oxygen carrying capacity in the blood. So even if 100% of the hemoglobin is carrying oxygen (hence sats of 100%), there is still less oxygen being delivered to the tissues if the hgb significantly decreased. To use the truck example, if you normally have 20 trucks delivering the load, but now you only have 5 trucks, less is going to be delivered. Saturation is only part of the picture for tissue oxygenation; yet, as nurses, we are taught be obsessed with that number.
    Last edit by psu_213 on Nov 18, '12
    MinnieMomRN, gypsyd8, JulieL, and 3 others like this.
  7. Visit  Anna Flaxis profile page
    0
    Quote from psu_213
    It is true that low hgb does not cause low sats, however low hgb can mean tissue hypoxia even in the setting of "normal" sats. If hgb is low that means there is less oxygen carrying capacity in the blood. So even if 100% of the hemoglobin is carrying oxygen (hence sats of 100%), there is still less oxygen being delivered to the tissues. To use the truck example, if you normally have 20 trucks delivering the load, but now you only have 5 trucks, less is going to be delivered. Saturation is only part of the picture for tissue oxygenation.
    Not only that, but if gas exchange is impaired d/t a hemothorax, then the O2 sats would be affected.
  8. Visit  psu_213 profile page
    0
    Just another theory: given the location of the surgery...is bleeding into the mediastinum possible? Did a slow bleed turn into a faster one? Was there some sort of sudden disruption to the hemostasis mechanism used during surgery?
  9. Visit  marcos9999 profile page
    1
    I'm pretty new at this but I was interested in your case so I did some research. Some causes of sudden loss of Hgb could be hemodilution, anticoagulants could loss through the digestive tract, stress can cause a lack of hgb production, kidney impairment could also cause hemodilution through water retention, Another reason for hemoglobin drop could be from destruction of red cells after receiving an allogeneic red cell transfusion, as seen in allergic transfusion reactions. Diet can also play a part.
    JulieL likes this.
  10. Visit  lckrn2pa profile page
    1
    I didn't read all the post but everything about this screams PE to me, within the 1st few sentences of your presentation.

    Recent surgery, central cyanosis, SOB,fever (common in PE pts). This is a PE until proven otherwise.
    CountyRat likes this.
  11. Visit  wish_me_luck profile page
    1
    was the pt given a plasma exchange before the thymectomy? I did some research and the sites say that plasma exchange can reduce blood and breathing complication post-op.

    http://www.myasthenia.org/LinkClick....Go%3d&tabid=84

    I want to know what happened pathophysiology wise to the patient. Good learning case.
    JulieL likes this.
  12. Visit  psu_213 profile page
    0
    Quote from lckrn2pa
    I didn't read all the post but everything about this screams PE to me, within the 1st few sentences of your presentation.

    Recent surgery, central cyanosis, SOB,fever (common in PE pts). This is a PE until proven otherwise.
    Could be a PE, but does that really explain the dramatic drop in hgb? Not that it can't be a PE and something else, but what is that something else?
  13. Visit  brillohead profile page
    3
    Another way to look at the oxygen saturation issue -- pulse ox measures the amount of oxygen that is being carried on an individual "chunk of hemoglobin". You could have a patient with a 100% sat level who is severely hypoxic and quite cyanotic, if they have a low hemoglobin count to begin with, because even if each chunk is carrying a full load (100%) of oxygen, there still won't be enough oxygen to go around to all the tissues that need it. You can't relate O2 sat levels to the amount of oxygen that is circulating in the body unless you know that the hemoglobin levels are satisfactory.

    Taking the truck analogy farther, let's say that a hypothetical body needs 90 cases of oxygen to maintain normal function, and a normal body has 100 pickup trucks driving around delivering oxygen and then refilling their load at the oxygen manufacturing plant, each truck carrying their full capacity of one full case of oxygen. Capacity carried by each truck = 100% load capacity = 100% O2 sat.

    Then five pickup trucks get flat tires and are out of commission, so you now only have 95 pickups each carrying one full case. You now have 95 cases available in the body, but each truck is still carrying 100% of its load capacity, so O2 sat is still 100%, even though the actual number of cases has decreased by 5% (started with 100 cases, now only have 95 in circulation). But that's okay, because we had a bit of a cushion built in -- we had enough trucks to carry 100 cases, but we really only need 90 cases to get by.

    Then there is a defective part on that model of truck, and twenty trucks all blow a head gasket at the same time. You're now down to only 75 trucks going around the body, but each truck still has a full case of oxygen, so O2 sat is still at 100%, even though there are only 75 cases available now instead of 100 cases like we started out. But with only 75 cases available, and with our previous statement that the body needs 90 cases in order to maintain normal function, we're going to start seeing some problems... we're running on an overall deficit because twenty-five percent of our trucks are out of commission. So even though all the remaining trucks are running at 100% capacity and we have a 100% O2 saturation level, we're turning blue because we are 15 cases short of the 90 cases we need for normal functioning.

    So now imagine that there's a problem at the oxygen manufacturing plant as well, and production is slowed considerably -- they can't even keep up with the demands of the 75 trucks that are still on the road. When a truck comes in for a fresh load, they can only give them 85% of a case. Now each truck is only carrying 85% of a load, so the O2 saturation level drops to 85%. But since we had fewer trucks (75) to begin with, that means that there are only 64 cases of oxygen available in the body. So even with an 85% sat level reading, we're only running at 64% of actual capacity.

    Hopefully this little story helps with mentally separating the O2 sat number from the actual volume of oxygen that is available to the body to use. Pulse ox readings are great, but always look at your patient first, the monitor second... remember, someone can be completely blue with a 100% O2 sat reading!
    Stcroix, morte, and JulieL like this.

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