Trek Tech Posted March 10, 2009 Share Posted March 10, 2009 I am having an issue with patients being sent to us for transfusion with an H&H from the nursing home of 8.1 & 24.2. When they reach our facility we draw an H&H for the record and we are getting 10.3 & 31.7. The transfusion is then canceled. I have communicated with the lab that does the work for the nursing homes and we ran each others tubes and got the same results. He is saying that they see this all the time. They draw the patients between 0300 and 0400. We draw them in the afternoon. I realize that ADH is circulating at night but I can not believe the huge differences we are seeing.Has anyone out there seen this type of diurnal variation? The only study I can reference is from 1939.P.S. It is multiple patients. We ruled out that the wrong person was drawn and all the usual suspect issues. Link to comment Share on other sites More sharing options...
Mary** Posted March 10, 2009 Share Posted March 10, 2009 :cries:Are they drawing the nursing home specimens through a line and not discarding a volume first? Link to comment Share on other sites More sharing options...
Lcsmrz Posted March 11, 2009 Share Posted March 11, 2009 I've seen patients with this type of Hgb variation before. Nursing home patients are usually drawn in the AM before they get out of bed. The clinician said there are fluid shifts that occur in the elderly outpatients after they get up, eat, and start moving around, whereas inpatients are usually in bed all day with little ambulation.Not sure how much of a variation would be seen, though. Link to comment Share on other sites More sharing options...
Trek Tech Posted March 11, 2009 Author Share Posted March 11, 2009 :cries:Are they drawing the nursing home specimens through a line and not discarding a volume first?Thought of that too. There are no IV's at the nursing home! Link to comment Share on other sites More sharing options...
Trek Tech Posted March 11, 2009 Author Share Posted March 11, 2009 I've seen patients with this type of Hgb variation before. Nursing home patients are usually drawn in the AM before they get out of bed. The clinician said there are fluid shifts that occur in the elderly outpatients after they get up, eat, and start moving around, whereas inpatients are usually in bed all day with little ambulation.Not sure how much of a variation would be seen, though.The Medical Director at the other lab is saying this is the reason. That the patient's are in bed in early a.m.. ADH, edema and morning meds (including lasix) all contribute to the difference. When they get up all the edema that was resolved and back in the blood stream comes back out and pools in dependant extremities. They get their lasix and hemoconcentrate as well. I have a Hem/Onc doctor that says that the variation is too great and he can't believe that theory.So, I am going to see if we can't require 2 H&H's collected at different times of the day to be considered before ordering a transfusion. Link to comment Share on other sites More sharing options...
John C. Staley Posted March 11, 2009 Share Posted March 11, 2009 Just curious, the patients with the 8 & 24 H&H in the AM. Are the symptomatic? Is there any sign of bleeding/blood loss? If not why are they even considering a transfusion in the first place? There is plenty of literature indicating that an arbitrary transfusion trigger is not a good idea. Link to comment Share on other sites More sharing options...
Lcsmrz Posted March 12, 2009 Share Posted March 12, 2009 Now THAT is an excellent point, John! I assumed that the transfusion was being ordered for symptomatic relief with a Hgb at around 8. But if the clinician is just chasing a number on a patient, then the transfusion was unwarranted, regardless of the Hgb.I found two references on normal Hgb variation in healthy adult males of 0.6 (bed, ambulatory). Throw in 75 years old, ASHD, COPD, diabetes, and who knows what else, and the 2 gm change does not seem that far out of the realm of possibilities. But I would throw in clinical symptoms to the transfusion trigger. Link to comment Share on other sites More sharing options...
Trek Tech Posted March 13, 2009 Author Share Posted March 13, 2009 I agree with both of you about the arbitrary transfusion trigger. However, we are not a hospital and most of our patients are either oncological or cardiac. The physicians do transfuse according to symptoms but also in response to vitals signs, EKG's and upcoming chemo. (The center is also a rehab center so the title of nursing home is misleading). Lcsmrz: Is the reference you found the one from the 1930's? I can not find anything more recent. Link to comment Share on other sites More sharing options...
jbporter Posted March 14, 2009 Share Posted March 14, 2009 When I worked at Wilkes Regional Medical Center, several times blood would be requested based on an early morning hemoglobin then the hemoglobin on the sample collected later in the day for the crossmatch would be as much as a gram or more higher. Both samples were rerun together on two separate instruments with the same results. The pathologist was consulted but the reason for the difference was never resolved. Link to comment Share on other sites More sharing options...
rescyth Posted March 16, 2009 Share Posted March 16, 2009 postural variation maybe responsible for that as some of the patients are prone to the postural changes where there is a shifting of fluids to the interstitial spaces of the body...i have an experience with this a long time ago...my friend draw this patient while lying down, then we did a redraw to confirm because of a sudden drop of the H/H, i personally redraw the patient together with my friend (patient already got up to pee) and the difference was very noticable, mine was higher that we did not need a transfusion...we did the usual investigation, confirm same patient was drawn, check instrument and rerun both samples... we got the same results from the reruns...we ruled out any patient misidentification and any technical/clerical error. The time gap between draws wasn't even >30 mins. Hope this helps. Link to comment Share on other sites More sharing options...
jbporter Posted March 19, 2009 Share Posted March 19, 2009 Guess the next question is how to make doctors more aware of this and hopefully decrease transfusions.jbp Link to comment Share on other sites More sharing options...
Trek Tech Posted March 19, 2009 Author Share Posted March 19, 2009 Guess the next question is how to make doctors more aware of this and hopefully decrease transfusions.jbpThankfully my physicians are dealing with it on a case by case basis. The blood bank is now requiring a second H&H after the patient has been up and about for a few hours. Out of 4 requests we have only tranfused 1. Unfortunately I can not get them to believe the difference is really due to postural or diurnal variation and they believe the real issue is the laboratory that the nursing/rehab facility is using. Link to comment Share on other sites More sharing options...
Trek Tech Posted March 30, 2009 Author Share Posted March 30, 2009 Finally, an answer! My colleague at the other lab found the answer to the hemoglobin variation. Mayo clinic did a study and it is called Postural Pseudoanemia: Postural Dependent Change in the Hematocrit. It is caused by just the things we discussed above. Here is a link to the article if anyone is interested:http://www.mayoclinicproceedings.com/content/80/5/611.shortThank you all for your input in this interesting problem! Link to comment Share on other sites More sharing options...
lgabbert Posted April 3, 2009 Share Posted April 3, 2009 I have noticed elderly patients at our hospital or from the nursing home with hemoglobins varying up and down, and have been curious as to why there is so much variation. I find these explanations very interesting!! Link to comment Share on other sites More sharing options...
Eloise Posted May 20, 2009 Share Posted May 20, 2009 My thanks to everyone. We have had this problem and the doctors thought that our lab values were in error, but we didn't have a good article to give them that would help reinforce what we were telling them about postural changes. Link to comment Share on other sites More sharing options...
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