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Thread: Why is Hemoglobin dropping?

  1. #1
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    Why is Hemoglobin dropping?

    A female patient comes in with a normal hemoglobin of 12.6, Next day she is 11.7, 3rd day she is 11.1., The patient has had very minimal lab draws such as CBC, & Lipid panel. What causes such significant drops in HB?

    This is typical of patients coming to hospitals.

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  3. #2
    What are her crits? What is the I& O of the patient. Even if you look at the I and O, from experience, it is rarely accurate. Want to find out, go look at how much a patient drinks and look at how much is charted.

    It could be from numerous reasons but if a trend, you might want to measure it and then present your findings to be reviewed by the doctors there. It could be something as simple as food or hydration or something more.

    It would be interesting.

  4. #3
    Managing Editor Jan B. Wade's Avatar
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    bolus infusion of saline - effect on hemoglobin

    Quote Originally Posted by Richard Casas View Post
    A female patient comes in with a normal hemoglobin of 12.6, Next day she is 11.7, 3rd day she is 11.1., The patient has had very minimal lab draws such as CBC, & Lipid panel. What causes such significant drops in HB?

    This is typical of patients coming to hospitals.

    We anticipated a hemoglobin drop in patients who were given a high volume infusion of saline. Here's a study showing same...

    ------------------------------

    "Does hemodilution exist? Effects of saline infusio...[South Med J. 1996] - PubMed Result

    Does hemodilution exist? Effects of saline infusion on hematologic parameters in euvolemic subjects.

    Grathwohl KW, Bruns BJ, LeBrun CJ, Ohno AK, Dillard TA, Cushner HM.
    Department of Internal Medicine, Madigan Army Medical Center, Tacoma, Wash. 98431-5000, USA.
    The effects of intravenous fluids on hematocrit are debated. We sought to determine whether maintenance or bolus fluid therapy causes a significant change in the hematocrit and other hematologic parameters included in the complete blood count. Nine subjects completed a randomized three-period crossover designed trial in which they were given no fluid, maintenance fluid, or a bolus of fluid followed by maintenance fluid. We measured complete blood counts at baseline, 1 hour, 4 hours, and 8 hours. In the bolus fluid trial, the hemoglobin and hematocrit values (mean +/- SEM) decreased by a maximum of 1.5 +/- 0.1 g/dL and 4.1 +/- 0.3% at 1 hour. There was no difference in hemoglobin or hematocrit during the no fluid or maintenance fluid treatments. No significant changes occurred in white blood cell or platelet counts. We demonstrated that maintenance fluid infusions do not significantly alter the complete blood count. Saline bolus is associated with a significant decrease in hemoglobin and hematocrit, but these parameters trend toward baseline over time."

    ----------------------------------

    This effect may be null when beginning values are high. However the judicious use of volume expander may be called for in trauma patients who have bled out to low values. Often the ER or first response protocol is to introduce volume quickly. This replaces volume but may actually impede O2 delivery (other mechanisms may also be at work besides the lowering Hg). Especially when surgery is anticipated and O2 delivery is of prime concern it would be important to consider judicious use of preop fluid infusion.
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  5. #4
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    Hemoglobin drop

    The reason the hemoglobin drops over the course of time in a hospital stay depends on the several circumstances. If the patient is in the ICU, then daily lab draws of 12 - 20 ml per draw will not be the sole contributor, but only another of several events that all together contribute to reduced red cell production, blood loss and hemodilution. Typically if the patient is in the ICU they will have a maintenance IV solution constantly running or a number of medication administrations which also contribute to dilution. Anticoagulant medications may cause loss in the digestive tract. Stress can cause reduced red cell production. Urine excretion may be diminished and/or kidney function depressed resulting in fluid overload and more dilution. Kidney disease is also associated with reduced red blood cell production. 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. Any or all of these events can affect patients outside of the ICU as well. Diet can also play a part. Typically this is an insidious event, but a combination of causes can make it more noticeable in the short term.
    Mark Lucas, MPS, CCP
    Blood Management Consultant

  6. #5
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    In that scenario where hemoglobin drops significantly in a female patient within a 3-day period, the possible reasons are: acute blood loss, dehydration which has been corrected during that period by oral of IV fluids, or systemic inflammatory process depressing the bone marrow or increasing destruction of RBC. One has to look for source of blood loss which may be occult; as one symposium speaker said "it may be anywhere between the nose and the anus." I have seen patients with sepsis who come in with normal levels of hgb which drops in the next few days. Dehydration increases Hct levels but IV fluids causes hemodilution and eventually lowers the hgb/hcts.

    Coagulation profile may also help in the diagnosis
    Angelina A. Gapay, MD

  7. #6
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    Stress ?

    Thank you for your responses. The patient was anticipating an angio procedure. All went well and she is now gone. The Drops in HB also had brought down the Crit. I can tell you that stress was present in this patient due to the wait.

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