Introduction:
Phlebotomy is usually done by inserting a cannula into a vein of the arm to withdraw the blood. The procedure itself is called venipuncture and is also used for intravenous therapy. A person who conducts a phlebotomy is known as a phlebotomist, but most doctors, nurses, and other technicians can also perform a phlebotomy. In contrast, phlebotomy is the surgical puncture of a vein to remove blood.
What Is Therapeutic Phlebotomy?
Phlebotomy is a process that involves the removal of blood from the body. Therapeutic phlebotomy is the treatment of choice for blood disorders where the removal of serum iron or excessive red blood cells is the most efficient way to manage symptoms and complications. Therapeutic phlebotomy is recommended for the treatment of non-alcoholic fatty liver disease with hemochromatosis, polycythemia vera, tardive cutaneous porphyria, sickle cell anemia, and hyperferritinemia.
Phlebotomy is an important treatment used by various groups from ancient times to the present day. Bloodletting has historically been performed using cupping, acupuncture, or leeches, but these procedures can sometimes be fatal. A famous example is George Washington (former US President), who died after losing 1.7 liters of blood while being treated for acute epiglottitis.
Where Is Therapeutic Phlebotomy Performed?
It is conducted under the supervision of a physician at a clinic, blood bank, or hospital physician. It can only be performed on a prescription clearly stating the clinical indications and number of phlebotomies required.
What Are the Various Conditions That Require Phlebotomy as a Therapy?
The various conditions that require phlebotomy as a therapy are listed below:
- Polycythemia Vera - Polycythemia vera is a Crohn's progressive myeloproliferative disorder with severe polycythemia, characterized by elevated production of red blood cells in the bone marrow, causing an increase in their number and blood viscosity. The production of white blood cells and platelets can also increase red blood cell proliferation. Therapeutic phlebotomy is the best choice for first-line therapy, and one of its main therapeutic goals is to reduce the risk of these thrombotic events. This is because patients with polycythemia vera are at increased risk of thrombotic events such as cerebrovascular disease and thromboembolism.
- Hemochromatosis - Phlebotomy does not improve hemochromatosis clinically but can prevent complications in patients with symptoms and organ damage. Continuous phlebotomy is recommended until the patient's serum ferritin level is less than 50 ng/mL and transferrin saturation is less than 50 %. In addition, clinical practice guidelines for the treatment of hemochromatosis, published by the American Association for Liver research in 2011, states that phlebotomy may help normalize tissue iron levels, improve patient survival and cardiac function, and reduce abdominal pain, has been shown to induce different therapeutic responses in hemochromatosis and pigmentation.
- Porphyria Cutanea Tarda - It is a disease characterized by low levels of uroporphyrinogen decarboxylase-associated uroporphyrinogen accumulation. Phlebectomy is the treatment of choice for this disease, and treatment with hydroxychloroquine is a good alternative. In such cases, phlebotomy should be repeated every two weeks until the Hb (hemoglobin) level is less than 20 ng/mL. Other studies suggest that this is a problem. For erythrocyte apheresis, it is an alternative to phlebotomy.
- Sickle Cell Disease - It may benefit from phlebotomy alone or in combination with hydroxyurea. This is because phlebotomy hemorrhage reduces Hb levels and mean cell Hb concentrations, reduces blood viscosity, and consequently reduces Hb polymerization observed in sickle cell anemia.
What Are Important Points to Consider Before Going for Therapeutic Phlebotomy?
- Patient factors such as age, sex, weight, comorbidities, general health, and the likelihood of adherence should be considered when prescribing a phlebotomy regimen.
- Therapeutic phlebotomy is a medical procedure. It requires a doctor's prescription. The prescription should indicate the frequency of phlebotomy and the target blood volume.
- Replacement fluids should also be prescribed for patients who cannot tolerate rapid loss of plasma. The prescription must clearly state the type, amount, rate, and duration of infusion.
- Patients with iron overload and chronic hemolytic anemia may not tolerate phlebotomy. Therefore, sound clinical judgment and careful monitoring are crucial in managing patients undergoing therapeutic phlebotomy.
What Are the Adverse Effects Associated With Therapeutic Phlebotomy?
- Thrombosis - Although phlebotomy is associated with rare adverse events, such as thrombosis (blood clot blocking vein and artery), patients with polycythemia vera have an increased risk of post-phlebotomy thrombosis.
- Hematoma - The most common adverse event is the development of a hematoma (collection of subcutaneous blood) at the donor site. Hematoma occurs in most patients. Although the disease is mild, severe cases can damage surrounding tissues, nerves, and blood vessels. The risk of hematoma can be reduced by applying pressure to the donor site. If a hematoma develops, compresses and ice should be used to slow bleeding.
- Fainting - Another common side effect is fainting. This is recognized by various symptoms, such as weakness, sweating, dizziness, and facial pallor. These symptoms may cause loss of consciousness or seizures. If the patient faints during phlebotomy, the tourniquet should be removed immediately, along with the needle, or the catheter occluded, and appropriate treatment should be initiated to relieve symptoms. A rapid decrease in blood volume may be accompanied by nausea and vomiting. In severe vomiting, blood sampling should be interrupted to initiate appropriate treatment. However, antiemetics (anti-vomiting medicine) are generally not recommended as pretreatment for phlebotomy.
How Is Therapeutic Phlebotomy Performed?
The therapeutic phlebotomy is performed in the procedure listed below:
- During a therapeutic phlebotomy procedure, blood is taken from the patient using a needle. This process is similar to donating blood. The doctor will decide how much blood to take from the patient.
- A small amount of blood is taken and discarded. The patient is then given an equal or greater amount of replacement fluid (saline) through the same vein. Blood is drawn gradually until the required amount of blood is finally reached.
- The therapeutic phlebotomy may take 1 to 2 hours, depending on the weight of the patient and the amount of blood drawn.
- Therapeutic phlebotomy can be repeated at regular intervals under the guidance of the doctor and ablation team. For conditions such as hemochromatosis and polycythemia, the procedure can be repeated over the years to help the patient lead a more normal life.
Conclusion:
Phlebotomy is the process involving the removal of blood from the body. Therapeutic phlebotomy is the treatment of choice for hematologic disorders, where the removal of serum iron or red blood cells is the most efficient way to manage symptoms and complications. Therapeutic efficacy and use of phlebotomy are recommended for polycythemia vera, hemochromatosis, porphyria cutanea tarda, sickle cell anemia, and hyperferritinemia. Additionally, phlebotomy can be considered part of managing patients with elevated serum iron levels. However, it is important to base treatment decisions on each patient's condition and relevant guidelines for prescribing and performing phlebotomy.
