Phlebotomy deals with the removal of blood samples from the body. Another type of phlebotomy is therapeutic phlebotomy which deals with the treatment of blood disorders, and it includes the removal of red blood cells to curb the signs and symptoms of the disease. Recently, therapeutic phlebotomy has been used to treat hemochromatosis, polycythemia vera, and sickle cell disease. Furthermore, phlebotomy treatment has been used in varied groups from ancient times to the present (Parapia, 2008). For the past decades, phlebotomy has historically been performed using cupping, acupuncture, or leeches, but the methods often resulted in death.
According to Zubair (2014), there are several physiological mechanisms of therapeutic phlebotomy. For example, bone marrow stem cells are stimulated by bloodletting to make red blood cells; the process requires iron transport from the body to create hemoglobin. Thus, irons are generally reduced in the body. Therapeutic phlebotomy is, therefore, the preferred treatment for blood diseases in which the removal of the red blood cells is the often used method for managing the symptoms and complications.
This report examines the significant indications for therapeutic phlebotomy and provides guidelines for phlebotomy, the accompanying effects, and their control. I will also provide helpful information that may help to facilitate the use of phlebotomy in the future.
Indications for Therapeutic Phlebotomy
Polycythemia vera is a clonal progressive myeloproliferative disorder associated with significant erythrocytosis. It is characterized by the unusual production of erythrocytes in the bone marrow, which leads to high blood viscosity. Although this disorder can be curbed by increasing white blood cells and platelets, the method can increase the risk of thrombotic events. Patients diagonalized with polycythemia vera have an increased risk of thrombotic events, like cerebrovascular disease, cardiovascular disease, and arterial or venous thromboembolism (Zubair, 2014). Due to this reason, medical physicians mostly prefer using therapeutic phlebotomy procedures to treat the disorder.
Phlebotomy prevents complications in patients with symptoms or organ damage, although it does not clinically improve hemochromatosis. According to Bacon et al. (2011), phlebotomy induces various therapeutic responses in hemochromatosis, including the normalization of tissue iron levels, improved patient survival and cardiac function, and reduced abdominal pain and pigmentation.
Sickle cell disease
Sickle cell disease can be controlled using phlebotomy. In Assi et al. (2014), phlebotomy decreases the blood’s viscosity by lowering the Hb levels and the mean corpuscular Hb concentration, which reduces the Hbs polymerization observed during sickle cell disease.
According to Aygun et al. (2015), (SWITCH) Store With Transfusions Changing to Hydroxyurea trial compared blood transfusions and chelation to hydroxycarbamide and phlebotomy for recurrent stroke and iron overload management in children with sickle cell anemia. In the study, transfusions were paused, and serial phlebotomy was conducted. After the maximum tolerated dose of hydroxycarbamide was reached, continuos therapeutic phlebotomy was performed after four weeks. The initial procedure was maintained at 5 ml/kg, with the subsequent phlebotomy increasing to 10 mL/kg with a maximum of 500mL in cases with Hb levels of ≥8 g/dl. Phlebotomy was only associated with self-limited adverse events, including dizziness, syncope, headache, and weakness. Interestingly, the SWITCH trial found that the net iron balance was favorable, with a significant decrease in ferritin levels, and concluded that phlebotomy was safe and well-tolerated, having removed net iron level for children who completed 30 months of protocol-directed treatment (Aygun et al. 2015).
Considerations Before Therapeutic Phlebotomy
Before introducing a therapeutic phlebotomy program in an institution, there must be established guidelines and regulations to ensure the patient’s safety, the phlebotomy procedure, and blood disposal. According to Roback (2011), Standard 66 of Practice Criteria III from the Infusion Nursing Standards of Practice established by Infuses Nurses Society provides phlebotomy regulations. The principles point that patient education regarding intra- and post-phlebotomy symptoms and consent, and more of, they include the training for staff regarding how to manage adverse effects and infections, how to reach blood vessels, venous phlebotomy techniques, patient safety, and basic cardiopulmonary resuscitation (Roback et al. 2011).
Also, it is advisable to consider patient factors such as age, sex, weight, comorbidities, health status, and the possibility of patient compliance (Zubair 2014). According to Zubair (2014), various criteria for initiating therapeutic phlebotomy include ferritin levels of >200 ng/mL for ages below 18 years for all sexes, ferritin levels of >500 ng/mL for non-pregnant mature women, and >300 ng/mL for men above eighteen. In his context, Zubair (2014) says serum ferritin and Hb levels are the most reliable measures for monitoring patients under therapeutic phlebotomy. Also, Zubair added that patients with ferritin levels (≥1,000 ng/mL) should be subjected to monitoring in a span of 2-3 months, and Hb levels should be checked during each phlebotomy visit. The frequent checking is because patients with pre-phlebotomy Hb concentration of <11 g/dL are more likely to experience symptoms of hypovolemia and anemia, and therapeutic phlebotomy is less efficient in depleting iron stores at a Hb level of <11 g/dL (Zubair 2014). A doctor’s prescription is also essential for therapeutic phlebotomy since it is a medical intervention. According to Zubair (2014), doctors should evaluate the patient’s blood pressure, pulse, respiration, temperature, hematocrit levels, and an arms inspection during phlebotomy. For the patients who require phlebotomy several times, a catheter may be inserted to collect blood, although only peripheral blood should be removed throughout the process. In addition, medical physicians must offer both sound clinical judgment and careful managing of patients under phlebotomy since patients with chronic hemolytic anemia and iron overload may not tolerate phlebotomy. According to Roback (2011), doctors’ recommendations should be clearly stated in the treatment guidelines at the relevant medical institution, and patient compliance recorded in their clinical records