Hemoglobin Drop
at the bedside
- unstable? BP, HR, perfusion first
- trend against baseline → how much, how fast
- spurious? drip-arm or wrong-tube sample → repeat before acting
- unstable or bleeding → two large cannulas, group & crossmatch now
escalate now if
- hypotension, tachycardia, poor perfusion → unstable or bleeding
- chest pain or syncope → transfuse
- visible active bleeding → resuscitate; melena or hematemesis → upper GI bleed
- Hb fall > 2 g/dL within 24 to 48 hr
- bleeding on an anticoagulant → hold and reverse
focused check
- bleeding → melena, hematemesis, hematuria, heavy menses; hidden: abdominal, back or thigh pain, post-procedure, falls; check PR, drains, line sites, hematomas
- hemolysis → jaundice, dark urine, recent transfusion
- dilution → after large-volume fluids
- over weeks → anemia workup in the morning, not tonight
- meds → anticoagulant (which, last dose), antiplatelets, NSAIDs
send now
- repeat CBC, RFT, LFT, coagulation; group & crossmatch
- hemolysis → LDH, bilirubin, haptoglobin, reticulocytes, DAT, blood film; transfused in the last 2 weeks → DAT
- imaging by the suspected site; stool occult blood if no visible source
treat
- unstable or bleeding → crystalloid 500 mL IV while blood arrives; blood is the fluid in hemorrhage; uncontrolled → massive hemorrhage protocol; find the source, call the specialty
- upper GI bleed → PPI 80 mg IV then 8 mg/h (pantoprazole or omeprazole); endoscopy within 24 h, sooner if unstable
- on an anticoagulant → hold; significant bleeding → reverse, doses on the coagulation page; senior decision
- transfuse → stable inpatient Hb < 7 g/dL; cardiovascular disease < 8; acute MI aim ~10; bleeding → to the patient, not the number
- one unit, then recheck: expect ~1 g/dL per unit
- no bleeding, stable → trend Hb, occult-bleeding and hemolysis workup, review marrow-suppressing drugs
- GI → hematemesis, melena, varices · surgery / IR: uncontrolled source · hematology: hemolysis, DIC, transfusion reaction · ICU: shock or massive transfusion
- hand over → trend, transfusion trigger, who to call if it falls again
calculator Glasgow-Blatchford (GI bleed) · MDCalc ↗︎
evidence
| source | type |
|---|---|
| AABB 2023 restrictive-transfusion guideline | international guideline |
| MINT trial 2023 (acute MI transfusion threshold) | major peer-reviewed trial |
Verify indication, dose, allergies, interactions, renal/hepatic function and local protocols before prescribing.
free the on-call checklist covers the whole shift on one printable page.
More clinical resources in the MOC+ Library →
reviewed Jul 2026updated Oct 2026file lab/cbc-hemoglobin-drop