Therapeutic Phlebotomy

While reading the 2021 spring nursing perspective, an article from Dalila Benhaberou-Brun caught my eye. As the title above suggests, it’s on the application of phlebotomy as a therapeutic tool. Phlebotomy, the process of drawing blood from a vein, is a rare treatment because most of the time people suffer from blood loss or reduced hemoglobin production. But, in rare cases such as iron surplus in the blood, phlebotomy is usually the invasive answer. The purpose of phlebotomy is to reduce the quantity of iron, stimulate the bone marrow and diminish the amount of ferritin in the body. Today I will discuss how the procedure is done and lightly go into the side effects of having too much iron in the blood.

Phlebotomy Procedure:

Since we are taking blood from the patient, it is important to ask the patient to drink around 500ml to a litre of water to compensate. In order to make the phlebotomy effortless a nurse is going to use a needle around 17G with an anti-reflux valve. The preferred spot to insert the needle is usually at the elbow crease. The veins are active and provide a constant flow of blood. Be sure to examine the veins before, in order to assess whether it is the best spot. Some people have veins that pop around their elbow crease. On the other hand, some people have veins that hide behind their elbow crease and the only available vein is on the wrist right behind the thumb. It usually takes between 15–20 minutes to fill a 500ml bag. During said time, the nurse is going to stay close in case the patient suffers from discomfort or faints during the process.

After the procedure the patient must stay another 10 minutes in the health center to ensure one last time that there is no discomfort or adverse effect on the patient’s blood pressure due to the phlebotomy. Because we use a 17G needle the bandage should stay on for a few hours to coagulate the blood and stop bleeding. Finally, the nurse is going to remind the patient, not to smoke in the next 2 hours and not to partake in physical activity for the next day.

Why would people voluntarily do a phlebotomy?

As said earlier in my introduction blood donations can help for a few sicknesses like hemochromatosis and polycythemia.

A) Hemochromatosis

Hemochromatosis results from a surplus of iron in the body. Hemochromatosis is a genetic disease caused by a human leukocyte antigen-linked (HLA) or a C282Y mutation (HHC gene). The HLA causes an antigen to link to hepcidin, leading to iron retention while the HHC gene affects the regulation hormone, hepcidin. The mechanism behind how HLA augments either iron retention or iron absorption are misunderstood (Duchini, Sfeir and Klachko 2017) but theories include the destruction or inactivation of hepcidin and increased amount of ferroportin in the system. On the other hand, the HFE C282Y and H63D mutation leads to reduced hepcidin and thus increased ferroportin (Peate, I 2014).

The signs and symptoms of hemochromatosis usually set in between 30–50 years. The most common and decisive symptom is the bronzing of the skin caused by augmented iron serum in the body. Because the iron is so high it can cause some degree of arthritis, Cirrhosis and even diabetes. Arthritis is caused by the sedimentation of iron in the hand’s articulations. The augmented concentration of ferritin above 300ng/ml will damage the kidney and cause Cirrhosis. It can get so severe as to potentially require a kidney transplant (Zakroka, Baranowicz-Gaszczyk and Zaluska 2021).

This leads back to why people who suffer from hemochromatosis benefit from regular blood donation. Unfortunately, it can be hard to know if you have hemochromatosis because it is such a late-onset disease. The only recommendation would be to screen people with the known disease and advise family members to regularly give blood donations to hospitals.

B) Polycythemia

Another illness that requires phlebotomy is polycythemia. Polycythemia can take two forms according to Antle (2010). Polycythemia Vera, the first type, is an augmentation of blood cells that are immature and mature. The consequence is an increased number of erythrocytes, hemoglobin, hematocrit, white blood cells and platelets. On the other hand, secondary polycythemia is caused by the augmentation of erythropoietin that causes Polycythemia Vera. Usually this can be observed with patients that take anabolic steroids which stimulate said erythropoietin.

Because there is so much happening in the blood, the spleen needs to work overtime, and people develop a splenomegaly. Another consequence is an increased difficulty to saturate blood with oxygen. What follows is diminished tissue oxygenation that can lead to symptoms like burning/tingling sensations in the lower extremities, dizziness and even arterial/venous thrombus or embolus.

Therapeutic phlebotomy allows patients with low-risk polycythemia to reduce symptoms or delay their appearance. Usually, giving blood in blood centers allows patients to save money on phlebotomy procedures while aiding other people that might need a blood transfusion according to Buren & al. (2020). Unfortunately, patients with high-risk polycythemia need to be stabilized with an array of medication (AAS, aggressive thrombolysis, alpha-interferon and radioactive phosphate) before being able to donate blood. The reason patients with high-risk polycythemia need to be stabilized is because they are at high risk for cardiac and cerebral infarction.

Conclusion:

According to these articles, the outstanding result is that phlebotomy is a cheap and subsidized solution to long term problems. Blood donations targeting people who could benefit from giving their blood because of illnesses like hemochromatosis and polycythemia should be a top priority because it becomes a win-win scenario for the giver and the receiver.

Reference :

Antle E. (2010). Who Needs a Therapeutic Phlebotomy? Clinical Journal of Oncology Nursing, 14(6), 694–696. https://doi-org.ezproxy.usherbrooke.ca/10.1188/10.CJON.694-696

Benhaberou-Brun, D. (2021). La phlébotomie thérapeutique. Perspective infirmière, 18(2), p30–31.

Buren, N. L. V., Hove, A. J., French, T. A., Gorlin, J. B., & Van Buren, N. L. (2020). Therapeutic Phlebotomy for Testosterone-Induced Polycythemia. American Journal of Clinical Pathology, 154(1), 33–37. https://doi-org.ezproxy.usherbrooke.ca/10.1093/ajcp/aqaa019

Duchini, A., Klachko, D. M., Sfeir, H. E. (2017). Hemochromatosis. Url: https://emedicine.medscape.com/article/177216-overview

Nemeth, E., & Ganz, T. (2009). The role of hepcidin in iron metabolism. Acta haematologica, 122(2–3), 78–86. https://doi.org/10.1159/000243791

Peate, I. (2014). Haemochromatosis: the role of the HCA and the AP in tackling iron overload. British Journal of Healthcare Assistants, 8(7), 328–333. https://doi-org.ezproxy.usherbrooke.ca/10.12968/bjha.2014.8.7.328