Indications of
venesection in
different scenario
Dr Sumithra Appava
Venesection = bloodletting
= therapeutic phlebotomy
The practice of bloodletting began around 3000 years
ago with the egyptians, then continued with the Greeks
and Romans, the Arabs and Asians.
Hippocrates believed that existence was represented
by the four basic elements earth, air, fire and water
which in humans were related to the four basic humors:
blood, phlegm, black bile and yellow bile
Being ill meant having an imbalance of the four humors
Methods of bloodletting
Generalized
Venesection
Arteriotomy
Localized
Scarification with cupping and leeches (hirudo
medicinalis)
Cupping
Fleam
Hirudo medicinalis
Famous bleedings
George Washington (1732 1799)
Developed fever and respiratory distress.
Had copious amounts of blood drawn, blisterings,
emetics and laxatives
He died the next night
Diagnosed retrospectively as epiglottitis and shock
Bloodletting today
Indications
Hemochromatosis
Polycythemia vera
Porphyria cutanea tarda
Hemochromatosis
Genetic disorder of iron metabolism leading to abnormal iron
accumulation in liver, pancreas, heart, pituitary, joints and skin
In the induction phase, weekly phlebotomy is made, with blood
removal of 7ml/kg per phlebotomy (not to exceed 550ml per
phlebotomy)
The efficacy of treatment is controlled by ferritin level evaluation
in plasma once monthly until the values remain above the upper
limits of normal (300mcg/L in men, 200mcg/L in women)
The Hb should be checked before each procedure
Subsequently, evaluation of ferritin concentration should be
perfomed bimonthly until its level is reduced below 50mcg/L
In the maintenance phase, the phlebotomy should be
performed every 2-4 months.
The interval between procedures is determined by the
level of ferritin, which should be lower than 50mcg/L
One study showed phlebotomy can reduce liver
fibrosis
Phlebotomy may improve or even cure some of the
manifestations such as fatigue, elevated liver
enzymes, hepatomegaly, abdominal pain, arthralgias,
and hyperpigmentation
Polycythemia vera
Stem cell bone marrow disorder leading to
overproduction of red blood cells and variable
overproduction of white blood cells and platlets
Phlebotomy can be done once or twice a week to
reduce the hematocrit to the range of less than
45%
Secondary polycythemia
At hematocrit levels higher than 60-65%, the compensatory increase
in red blood cells reaches the limit of benefit and begins to
compromise circulation because of hyperviscosity.
Some patients with extreme secondary polycythemia have impaired
alertness, dizziness, headaches, and compromised exercise
tolerance. They may also be at increased risk for thrombosis,
strokes, myocardial infarction, and
deep venous thrombosis. These are the patients who require phlebot
omy.
The optimal level of hematocrit is one that is as close as possible to
normal without impairing the compensatory benefit of increased
oxygen delivery. This may be determined individually by symptom
relief or decompensation, depending on the viscosity level.
A recent randomized trial demonstrated a significant
difference in the rate of thrombotic events and CVS deaths
(2.7% vs 9.8%) when the HCT goal was 45% vs 50%
Patients with severe plethora who have altered mentation or
associated vascular compromise can be bled more vigorously,
with daily removal of 500ml of whole blood
Elderly patients with some cardiovascular compromise or
cerebrovascular complications should have the volume
replaced with saline solution after each procedure to avoid
postural hypotension
Porphyria cutanea tarda
Group of disorders of heme metabolism with an
associated abnormality in iron metabolism
Therapeutic phlebotomy reduces iron stores, which
improves heme synthesis disturbed by ferro-mediated
inhibition of uroporphyrinogen decarboxylase (UROD).
The goal of therapy is to reduce serum ferritin levels to
the lower limit of the reference range.
Venesections may be scheduled at intervals
ranging from a unit of whole blood removed twice
weekly to every 2-3 weeks as tolerated by the
patient.
Care should be taken to not induce anemia
(hemoglobin < 10-11 g/dL).
Phlebotomy is the preferred therapy for individuals
with a heavy iron burden
Other indications
In the last 25 years, leech therapy has made a
comeback in the area of microsurgery and
reimplantation surgery.
Hirudo medicinalis can secrete several biologically
active substances including
Hyaluronidase
Fibrinase
Proteinase inhibitors
Hirudin anticoagulant
The leech can help reduce venous congestion and
prevent tissue necrosis
Can be used in postoperative care of skin grafts
and reimplanted finger, ears and toes
Because of concerns of secondary infection, a
mechanical leech has been developed at the
University of Wisconsin
In a randomised controlled trial Leo et al. observed that iron
reduction by phlebotomy can lower the risk of cancer
occurrence (38 malignancies vs 60 in group in which iron
reduction therapy was not used; hazard ratio 0.65; P=0.036).
They also observed a lower mortality among phlebotomised
group (hazard ratio 0.49; P=0.009)67.
However, the study had some limitations: it was originally
designed as a cardiovascular disease study and not to
compare risks of cancer between the two groups.
Patients with metabolic syndrome who underwent iron
reduction by phlebotomy had statistically significant
differences in systolic blood pressure, glucose, HbA1C,
HDL cholesterol, iron and ferritin compared to controls
(P<0.001).
LDL cholesterol also decreased but not to a statistically
significant degree (P=0.16)68.
However, the authors indicated that this trial had some
limitations
Patients with sickle cell disease (SS or SA) may also benefit
from phlebotomy alone or in conjunction with hydroxyurea.
Phlebotomy decreases the viscosity of blood by reducing the
haemoglobin level and causes a reduction of the mean
corpuscular haemoglobin concentration which, in turn,
reduces HbS molecule polymerisation in sickle cell disease
In a study of seven children with sickle cell disease suffering
from frequent painful crises, Bouchair et al. demonstrated
that frequent phlebotomies done over a period of 4 years
were able to significantly decrease the number of days
passed in hospital from 144 days annually to 20, 5, 6 and 1
day, respectively, over the 4 years of observation.
Thank you
