What would cause Hgb to plummet?

[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?

[wish_me_luck, BSN, RN]

DIC/sepsis? Did you find out yet?

[squatmunkie_RN]

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

[Anna Flaxis, BSN, RN]

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?

[tewdles, RN]

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.

[Esme12, ASN, BSN, RN]

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.

[Esme12, ASN, BSN, RN]

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!

[psu_213, BSN, RN]

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.

[Anna Flaxis, BSN, RN]

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.

[psu_213, BSN, RN]

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?

[Leonardo Del Toro, RN]

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.

[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.

[wish_me_luck, BSN, RN]

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.aspx?fileticket=BIVoreOXJGo%3d&tabid=84

I want to know what happened pathophysiology wise to the patient. Good learning case.