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?

[psu_213, BSN, RN]

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?

[brillohead, ADN, RN]

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!

[AlphaPig]

Ok, update on the patient. I was not able to look at her chart (because now with electronic charting you can trace everyone who looks at the chart and since I am not her nurse anymore, I could get into trouble) but I was able to glean some information from her doctor and the patient herself (who I visited on the step down room she is now in).

All of her scans were negative - she is not bleeding anywhere.

They gave her 2 units of blood and her Hgb went up to 9.0 where it stayed for two days before dropping to 8.2 the day I visited her.

The doctors have no idea why her Hgb refuses to stay up. Her admitting doctor told me they consulted Hematology but they haven't seen the patient yet. He said they are trying to put all the pieces together - her surgery, her auto-immune disorder, her lung spasms (which has pretty much resolved) - to figure out what is going on.

The patient appeared much better to me - no cyanosis, no SOB while resting, O2 sat 96% on 2L NC. Pt stated her right flank pain was now being controlled by her pain medicine and the spasms have pretty much stopped. Pt still feels weak.

So. . .basically they still don't know what is going on. I will continue to try to follow her case and will let you know. I wish I could see her chart.

[netglow, ASN, RN]

hematologic malignancy

[FranEMTnurse, CNA, LPN, EMT-I]

I had septicemia once. Would this cause a log hgb count? I was given 2 units of blood.

[morte, LPN, LVN]

yeah, maybe she doesn't even have MG...

hematologic malignancy

[Grumpy's Girl]

One more tidbit for the truck analogy: Less trucks, though with a full load, must work faster to deliver the goal amount, even faster if they are carrying less load on less trucks. Hence tachycardia. Hence increase RR to fill those less trucks that are running faster with O2.

As RRT members we encourage - esp new RNs- to call with questions if their senior nurses can't answer. One of the "triggers" to call RRT is the RN is "worried" about how their pt is doing. I guess "worried" is that developing nurse sixth sense that this patient has the potential to crash whether you can get the MD to feel it or not. The RRT will help you put together the pieces to see what has developed and what is probably coming and how to nip it in the bud or d/w MD. Those are good calls - nipping it in the bud. Each call is a learning experience. We teach and think out loud with the RN (and the family). It has been neat, now, to see that many times, by the time we get to the room, the nurses who called us have already started our routine. Talk about nipping it in the bud. We are a team. We have more pts getting over the crisis and staying in the room.

This is just a RRT aside. So keep in touch with your RRT resources.

Glad your pt is doing better, hope her mystery is solved soon.

[alfa-sierra, BSN, RN]

Yes, only 5 trucks instead of 20. Yet, 5 trucks may be compensatorily overloaded and the total load still be close to what 20 normally loaded trucks would carry. That may explain why the blood drawn looked so thick and dark- more O2 clinging to fewer cells, fewer hemes, more O2 reacting with the same iron per cell.

[jacrabbitrn]

still don't get the truck thing

[psu_213, BSN, RN]

still don't get the truck thing

Uh, how so. It was an analogy...and I don't think it was that difficult to understand, although I could be wrong. What about it did you not understand?

[Anna Flaxis, BSN, RN]

Thanks for the update!

[SarahB84]

It's hard on the floor (when I had 5 other patients) to truly stop and take a good look at the whole clinical picture. I feel like as floor nurses, we tend to focus on the task at hand/main problem and don't have the time to ever put all of the pieces together/get a feel for the whole person.

the above statement is true and scarey, because of this i no longer wish to work in a hospital.