Therapeutic Phlebotomy Techniques – A Patient’s View

Posted April 18th, 2014 by webadmin

An open letter by Rob Bickerdike, a patient with hereditary hemochromatosis

Intended Audience: All facilities providing therapeutic phlebotomies to hemochromatosis patients (Hematologists / Oncologists, blood banks), as well as people who have been diagnosed with hereditary hemochromatosis (HHC).

Purpose

I am preparing this document for the following two reasons:

1. To ask those health care professionals who provide therapeutic phlebotomies to patients with hemochromatosis, to consider the substantial benefits of using an 18 gauge IV catheter for phlebotomies, instead of the commonly used 15 or 16 gauge metal needle attached to standard blood bags.

2. To inform HHC patients of this alternative so they can initiate the necessary dialogue with their health care providers

The equipment needed to use an 18 gauge IV catheter is a blood bag with no attached needle, just a luer lock that allows you to easily attach any size needle.  Such a blood bag is readily available in the market.  All it takes is an awareness of the benefits and an interest in providing care that is best adapted to a specific patient’s needs.

Since I travel between Canada and the USA, and have used such services in both countries, my observations and recommendations are made in the light of my experiences in these two countries.  Estimates indicate there are probably over 100,000 Canadians and one million Americans with Hereditary Hemochromatosis.  Many of these people will not be fortunate enough to have been born with easily accessible large elbow or lower arm veins and for them, therapeutic phlebotomies can be a nightmare, as they were for me.  That’s a lot of people whose lives can be improved with a few simple changes.  Using the techniques I describe in this paper can greatly facilitate phlebotomizing these folks and have a significant impact on their quality of life.  This was, and still is, my situation and the techniques described here were used over and over in my case with great success.

Background

I am a patient, not a doctor or nurse, who has hereditary hemochromatosis. I was diagnosed at the age of 59, with a double c282y mutation, and fairly significant levels of ferritin, as well as hemosiderin deposits in the liver, which were visible via MRI. Given my condition, my hematologist recommended aggressive de-ironing, and initial phlebotomies were scheduled once a week.

Patients with hereditary hemochromatosis are often diagnosed only after they become symptomatic, and have accumulated significant levels of iron in their bodies. The usual course of action is to “aggressively de-iron” the patient to remove such accumulations and then place the patient on a maintenance program for the rest of their lives.

The aggressive de-ironing phase can involve phlebotomies as frequently as one to three times a week, for a year or even two years, depending on how much iron is stored.

Clearly, it is most important to maintain vascular access to perform all these phlebotomies. Using a standard blood bag with an attached 15 or 16 gauge metal needle is neither ideal, nor necessary, for many patients. A far better option is an 18 gauge teflon coated IV catheter. Even smaller IV needles (20 gauge) can be used for patients whose blood does not coagulate too quickly (those on anticoagulants like warfarin, etc). I personally take warfarin, and am routinely phlebotomized using a 20 gauge IV catheter from the veins in my hands. It takes less than 15 minutes to draw 600 ml of blood and there is no post procedure pain whatsoever. Nor is there any bleeding or hematoma (bruising) to speak of. A few hours after the procedure you can barely see the venipuncture site.

I can assure you this was not the case with a 16 gauge metal needle. Before discovering the possibility of using smaller IV catheters, I was initially phlebotomized with 16 gauge needles. Every time, my arm was sore afterwards for a couple of days, and finally the one elbow vein I had that could accommodate such a large needle collapsed and stopped giving blood. If it were not for the realization that smaller gauge IV catheters could be used in the smaller veins of the hands and lower arms, I would undoubtedly have a Port-a-cath installed in my upper chest now. The nurses who initially phlebotomized me with the 16 gauge steel needle, recognizing that my one, very short, elbow vein would not last forever (in fact, it lasted only three phlebotomies with the 16 gauge needle before collapsing), talked to me about getting a Port-a-cath like it was the same as getting a new pair of shoes – no big deal. This attitude has got to change. These devices are not without risk and installing them in a cavalier fashion because of the subsequent convenience they provide for hospital staff is unreasonable. Every effort should be made to preserve venous access and avoid unnecessary recourse to Port-a-caths, and indeed much can be done – all it takes is an open mind, and a genuine interest in providing care that is best adapted to an individual patient’s needs.

The shortcomings of the 15 or 16 gauge metal needle

The metal 16 gauge needle has several drawbacks, by comparison with the IV catheter:

  • It limits the number of veins that can be used (typically elbow veins provide enough volume for such a large needle, but veins in the hands or lower arms do not).
  • It scars the veins to a greater extent than the smaller and more flexible IV catheters do, and hence reduces the usable life of veins. A steel needle held steady by a phlebotomist, in an ideal world, would be stationary inside your vein and hence not be scratching the inside of the vein. In the real world, there are many distractions that occur over the course of a phlebotomy and the phlebotomist invariably moves the needle to some degree. The tip of the needle is very sharp and hence there is the potential to scratch the inside of the vein. When an IV cathether is used, after the initial venipuncture, the needle is withdrawn and only a flexible plastic tube remains inside the vein, with most certainly a far lesser propensity to do damage to the inside of the vein.
  • It results in more post procedure pain and hematoma than the smaller IV catheters. This is significant when the patient is being phlebotomized one, or more, times a week. Their arms hurt for a number of days, each week, week in and week out, and this potentially for a year or more.
  • It results in substantially more post procedure bleeding and hematoma for patients who are anti-coagulated (on warfarin, etc)

Why are IV catheters not in use now for therapeutic phlebotomies?

A few reasons:

  • Lack of awareness that there are alternatives – truly, every health professional I mention this to, initially rolls their eyes (are you doing that now!!??).
  • Inertia – “we’ve always done it this way” or “this is our business and we know what we’re doing”, or “this is the equipment they give us and that’s what we use”…… any of this sound familiar??
  • Speed. After all, time is money, right? The phlebotomy goes faster with a 15 or 16 gauge needle than it does with an 18 gauge needle. Although, in terms of labour, I notice that nurses attend a patient full time while phlebotomizing with the 16 gauge steel needle (they hold the needle in place manually). An IV catheter can be taped in place, without fear of damaging the inside of the vein, and the nurse can move on to care for other patients (needing only to keep an eye on the amount of blood in the bag to determine when to end the phlebotomy). So, there is potentially a real saving in labour.
  • Cost – I suspect that the standard blood bag with the attached needle is the least expensive equipment arrangement.
  • The folks who provide therapeutic phlebotomies do other things as their principal services.

Hemochoromatosis patients, in my experience, are phlebotomized in three settings.

In Canada, such phlebotomies are offered by hospitals (typically in the Hematology / Oncology department), or by blood banks.

  • The primary function of blood banks is to maintain the nation’s emergency supplies of blood and the vast majority of their donors are not hemochromatosis patients.  Their donors give blood at a maximum frequency of about two months, and for many donors it is an admirable once or twice a year social contribution.   The use of a steel 16 gauge needle for these donors is efficient (the blood is drawn relatively rapidly), and the large needles allow red blood cells to pass through them without rupturing (which might be the case with smaller needles, rendering the collected blood useless).   In any event, donors’ veins have ample time to recover before the next donation.  For the hemochromatosis patient undergoing aggressive de-ironing, this is far from their reality.  But, since the 16 gauge needle is appropriate to maintain the integrity of the blood collected, this is the standard that is used and a one-size-fits-all approach is taken.
  • In the case of Hematologists / Oncologists, their primary patient load is cancer patients.  The needs of Oncology patients, however, are quite different than that of those with hemochromatosis.   Once again, since providing therapeutic phlebotomies is not their primary area of endeavour, it appears that the majority have simply adopted the most widely known approach (the standard blood bag used by blood banks).

In the USA, therapeutic phlebotomies are offered by doctors practicing in the fields of Hematology  / Oncology, or at Blood Banks.  The same comments as for Canada apply; the standard procedure is to use a blood bag with an attached 16 gauge needle.

Equipment needed to use an IV catheter

  • The simplest arrangement is to use a 600 ml blood bag that comes with no needle attached to it. In place of the needle, there is a luer lock, to which any needle can be attached. The only supplier of such a bag that I have found so far is MacoPharma Inc and the bag model number is VSL 7000YQ (or just ask for the “therapeutic phlebotomy blood bag equipped with a luer lock”). This bag also has a port to insert vacuum tubes for taking blood samples. A most excellent bag for the hemochromatosis patient. The contact information for obtaining these bags is found at the end of this document. Incidentally, I have no vested interest in this company (other than being a customer for their bags) although I certainly hope they stay in business and keep making and selling this product! If anyone knows of a similar product, made by another company, please let me know and I will be happy to include it in any revisions to this article.
  • If the MacoPharma bag is unavailable for any reason, it is possible to attach an IV catheter to a standard blood bag with attached 16 gauge needle, by using an extension set and injection cap with male luer lock. Such an arrangement is described in Appendix 2, of a document entitled Iron Overload – Investigation and Management, found on the website of the Ministry of Health of the province of British Columbia in Canada, at the following web address: www.health.gov.bc.ca/gpac/guideline_iron_overload.html#appendix2.

Additional Considerations

  • As a patient, I find that the arm support I am asked to use when being phlebotomized is too high. I asked the phlebotomists why this is and they tell me it is so they don’t have to bend over too much in order to protect their backs. In my case, blood is drawn from my hands. Invariably I sit in a chair with my arm on an arm rest that is somewhat high, and then the phlebotomist further raises it by putting a folded towel under it. In some cases the arm of the chair has an extension built on top of it to raise it further. Now the hand is so high that the veins are not very engorged with blood and the phlebotomist starts to hit them to make them rise. I understand the phlebotomist’s desire to protect their backs, but at some point this is ridiculous. If blood is to be drawn from the hand, simply lower the hand as much as possible to increase the dilation of the veins. This is not rocket science. Try it yourself. Raise your hand above your head and see what your veins look like (they disappear completely). Then, sit in a chair and bend over to hang your hand near the floor. Hold it in that position for 30 seconds and the veins begin to bulge out. Obviously, this is not the position I am advocating, but you get the idea – position the hand as low as practically possible – if the hand is almost at heart level, the veins are not going to be very prominent. The best results are when I rest the hand on a thin cushion or towel in my lap.
  • Advise patients to keep their bodies as warm as possible. Doctors’ offices, etc are often quite cool, and in such an environment the veins seem to just disappear. To keep my arms warm I use heated gel packs. A hot environment that is also moist, really helps to raise the veins (to see this effect, when you are taking a hot shower, hold your hands down by your sides and you will see the veins very engorged with blood and very prominently raised). In my case, since most of my good veins are in my hands and lower arms, I wear rubber gloves (like for doing the dishes), that cause the hands to sweat a bit and so keeps them in moist environment. I keep a hot water bottle in a cloth bag slung over my shoulder so I can keep my rubber gloved hand resting on it. The hand is then kept quite warm and moist and the veins really stand up. Simple, but very effective.
  • To minimize the number of venipunctures consider using an instrument that uses a drop of capillary blood (from a finger stick) to measure hemoglobin levels prior to phlebotomies. Some of these are quite affordable – an example is the HemoCue Hb201+. Looking at their pricing it seems to me it would be a much less expensive option than a traditional blood draw and lab analysis, and certainly much better for the patient. Again, I have no relationship with HemoCue – I simply reference their product as an example of an affordable instrument. I would be happy to list others, if anyone would like to make additional suggestions.

Contacts

For the MacoPharma phlebotomy bags equipped with a luer lock attachment (you can attach any size needle you like):
Quote Model number VSL 7000YQ (600 ml capacity), or ask for the “therapeutic phlebotomy blood bag equipped with a luer lock”, in the event the company has changed the model number.

In Canada contact:
MacoPharma Canada Inc
1080 Beaver Hall Hill, Suite GR-002
Montreal, Quebec, H2Z 1S8
Tel: 1-866-870-6226

In the USA contact:
Macopharma USA
3675 Crestwood Pkwy., #260
Duluth, GA 30096
Tel: 770-270-6867
A brochure on their website at the following address, in Oct 2013, shows the availability of a “therapeutic blood bag available with a luer lock”. http://www.macopharmausa.com/images/PDF/Products/xn3aa01a%20phlebotomy%20bag%20brochure.pdf

For instruments to check hemoglobin levels using capillary blood (finger stick)
In USA and Canada
www.hemocue.com

Disclaimer:  The information and opinions expressed in this article are not those of a health care professional.  They are those of a patient with no formal medical training, and are simply based on his direct experiences and observations as a hemochromatosis patient.  The intent of the document is to request the medical profession to consider these experiences and observations, and respond by adapting the treatment delivered to hemochromatosis patients where appropriate, and to inform HH patients that there is an alternative procedure that will help preserve their veins – veins they will need for the rest of their lives.