Therapeutic phlebotomy

Who does this at your institution?  Is there a difference in who does it between inpts and outpts?  Lab techs/blood bank MTs?  IV team nurses?  Staff nurses?  Does anyone have any policies they could share?  I looked on the downloads and there is nothing that addresses this particular procedure.  TIA.
Forums: 

 Does anyone have a therapeutic phlebotomy patient that has exhausted all peripheral veins? Is it acceptable to just place a midline us guided above the ac fossa for this? Has anyone experience a patient that had a fistula placed for this purpose? Who would draw the blood from a fistula? Would that be an US guided procedure?

Celia Brown

 No standard for weight vs volume for this procedure,no evidence for such a standard. Lynn

Lynn Hadaway, M.Ed., RN, BC, CRNI

Lynn Hadaway Associates, Inc.

126 Main Street, PO Box 10

Milner, GA 30257

Website http://www.hadawayassociates.com

Office Phone 770-358-7861

I thought TP by weight was the standard practice! That's how I learned to do it!

Keith W. Gilchrist, RN, BSN, OCN, CRNI, VA-BC
Oncology Nurse Navigator, David Grant Medical Center
Travis AFB, CA

 So measurement by weight instead of volume, interesting! Sure wish you would published this procedure as there is very little in the literature about this procedure. Lynn

Lynn Hadaway, M.Ed., RN, BC, CRNI

Lynn Hadaway Associates, Inc.

126 Main Street, PO Box 10

Milner, GA 30257

Website http://www.hadawayassociates.com

Office Phone 770-358-7861

Our LIPs indicate in the order to withdraw "one unit" or "two units" of blood. We infuse 500 mls of saline in between the two units. The 2 unit withdrawals are for patients with hematocrits in the 60s an 70s. Our TP scale is calibrated to a wt that is the wt of one unit so when the scale trips, we have one unit of blood in the bag.

Competency is a constant struggle on the inpt side. We usually have one pt about every six months who needs this and usually they need several units taken off over several days to get their hct down to mid 40s. I created a ppt with pictures for each step and all the nurses in our MICU and our oncology unit have access to it. It can be reviewed in about 5-10 min for those who just need a refresher.

CardioMed was the company at the INS Convention. We love them. Lowers risk of blood exposure and needle stick injury  Bag measures up to 500 ml. Markings are on the bag for lesser amounts. No guessing or fat bags. No more piecing equipment. Everything you need is part of the system 

 The amount of blood withdrawn on a TP definitely requires an order from the LIP for a specific amount to be withdrawn. This is addressed in the INS Standards, page S79. For several years now, a product has been exhibited at INS for this procedure. It is a plastic bag with a method to accurately measure the amount withdrawn. Sorry I don't remember the company name and don't have the convention journal handy to look it up. Lynn

Lynn Hadaway, M.Ed., RN, BC, CRNI

Lynn Hadaway Associates, Inc.

126 Main Street, PO Box 10

Milner, GA 30257

Website http://www.hadawayassociates.com

Office Phone 770-358-7861

I have done many therapeutic phlebotomies as well. In the past most of the ones I did were as a part of a partial exchange for sickle cell patients. The doctors wrote very specific orders as to amts in and out. We used to have the vacutainer bottles to use for the withdrawals and those were very nice. We knew exactly how much blood we were taking. When the manufacturer stopped making those we had to get creative. Now I'm in a new facility and we don't do the exchanges but we still may be asked to do TP from time to time. But since our Hoxworth does them for free for people we don't get many. I just need some feed back and hopefully references to see how to proceed. Our policy states, "Withdraw 400-500ml blood or as specified by the physician." and we use blood bags which hold 400ml and if made "fat" its approximately 500ml. Is that estimation acceptable? Or do we need to be definite on the amt removed. These patients have hemochromatosis or polycythemia so it's an entirely different reason than my sickle cell patients in the past. And I may be over-reacting to the procedure as they just need blood removed and though there is a risk of causing temporary anemia as long as blood count parameters are followed pre TP maybe it's not as significant to get an extra fat bag every now and then? I would like to look at some evidence based research and practice guidelines?? I have been researching my books and on line. I'm either looking in the wrong places or there is very little out there. I'm desperate! Please help!

Debbie Graham BSN, RN, CRNI, VA-BC

 

"It takes many people to make a team, but only one to break it" --A. R. R. Tripp

 I have done numerous therapeutic phlebotomies in the past and have always had the order specify the exact amout to take off. I would question any order without that information. Lynn

Lynn Hadaway, M.Ed., RN, BC, CRNI

Lynn Hadaway Associates, Inc.

126 Main Street, PO Box 10

Milner, GA 30257

Website http://www.hadawayassociates.com

Office Phone 770-358-7861

We had a joint commission surveyor say that he has seen hospitals sited for not having a doctor's order specify the amount of blood to take, during therapeutic phlebotomy.  Have you heard that?

I know that the INS standards say the order should include an amount.  I guess we had one that didn't.

Gwen

The rationale would be based on the catheter lumen size and the thick viscous blood when therapeutic phlebotomy is needed. The catheter lumen size may not allow sufficient flow rates for aspiration of this thick blood. Also fibrin sheaths and other mechanical problems could prohibit adequate backflow of blood. I am not aware of any studies showing success rates with this procedure through these catheters. It is also possible to have this procedure contribute to the risk of catheter occlusion, preventing the use of the catheter for prescribed infusion. 

Lynn Hadaway, M.Ed., RN, BC, CRNI

www.hadawayassociates.com

Lynn Hadaway, M.Ed., RN, BC, CRNI

Lynn Hadaway Associates, Inc.

126 Main Street, PO Box 10

Milner, GA 30257

Website http://www.hadawayassociates.com

Office Phone 770-358-7861

The INS standards state that a PICC Midline or implanted port should NOT be used for therapeutic phlebotomy...What is the rationale behind this.

 Darla Tarvin RN VA-BC

Mercy Clermont Hospital

I just completed a revision on our policy to include two methods.  I would be happy to share, email me your info dskupien@rsh.net and I will send it to you.

This is typically done in our outpatient infusion center but can happen on the floors when the patients are inpatient.  Our institution requires competency for this procedure and it has to be done by an RN>

The nurses staffing the Outpatient Infusion Center does it at our institution.  Outpatients make an appointment and come in for the TP.  If an inpatient needs TP, the floor calls the Outpatient Center.  We go up to the patient room and do the TP during departmental down time.

 We do have a written policy, I pasted from our pdf file below. 

Also, our Local Community Blood Center will also do TP at no charge. 

PURPOSE:

Therapeutic Phlebotomy is a temporary treatment for patients who have an excessive accumulation of cellular

iron, or an increased concentration of red blood cells.

PRINCIPLE:

Therapeutic phlebotomy is done as treatment for medical condition or indication. The ordering physician must

specify the amount of blood to be drawn and how often phlebotomy should be performed (or a

hemoglobin/hematocrit level at which the phlebotomy should be performed). Once drawn, the blood is not

intended for transfusion and is discarded after the procedure is completed.

QUALITY CONTROL:

Confirm the patient’s identity against the physician’s orders for the therapeutic phlebotomy.

MATERIALS/SUPPLIES:

A. 16-18G needles/angios

B. Tourniquet

C. Phlebotomy bag,

D. gauze

E. Hemostat

F. Alcohol preps

G. Adhesive tape

H. Outpatient Discharge Instructions, Phlebotomy

PROCEDURE:

Appropriate safety precautions must be followed.

A. Prepare patient

1. Labs if ordered

2. Blood Pressure

** If blood pressure is less than 90 systolic and/or the pulse is greater than 130 beats per minute,

contact the physician before proceeding with the phlebotomy.

3. hct/hgh if requested

Review the hematocrit cut-off value ordered by the physician. If the patient’s hematocrit is below

the cut-off level, explain to the patient that a phlebotomy is not necessary. Document the

hematocrit results on the Therapeutic Phlebotomy Patient Worksheet.

B. Prepare the venipuncture site.

1. Apply a tourniquet or blood pressure cuff and locate an appropriate venipuncture site. Ideally,

blood should be drawn from a large, firm vein. Release the tourniquet.

THERAPEUTIC PHLEBOTOMY

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a. Avoid areas with skin lesions.

2. Cleanse venipuncture site with alcohol starting at the intended site of venipuncture and moving

outward in concentric spiral. Let stand for 30 seconds. Do not repalpate the vein at the intended

venipuncture site.

C. Phlebotomy

1. Inspect the phlebotomy bag for any defects. Attach appropriate needle and clamp tubing with

hemostat.

2. Position the bag carefully, being sure it is below the level of the patient’s arm.

3. Have ready some hemostat and adhesive tape.

4. Apply the tourniquet or pressure cuff. Ask the patient to open and close his hand until the

selected vein becomes prominent.

5. Uncover the sterile needle/angio and perform the venipuncture.

6. Tape the tubing to hold the needle in place and cover the site with a sterile gauze. Release

hemostat.

7. Release tourniquet and re-apply loosely.

8. Ask the patient to open and close his hand, squeezing a rubber ball or other resilient object

slowly every 10-12 seconds during the collection.

9. Observe the patient during collection. The patient should never be left unattended during or

immediately after the donation.

10. Be sure blood flow remains fairly brisk.

11. Monitor the amount of blood collected until bag is filled.

12. Remove the tourniquet.

13. Clamp off tubing.

14. Remove the needle/angio from the patient’s arm.

a. Apply pressure over the gauze and ask the patient to raise their arm straight and hold the

gauze firmly over the phlebotomy site with their other hand.

15. Discard the needle into a hard, plastic biohazard container.

16. Therapeutic phlebotomy blood can not be used for transfusion. Discard the unit in an

appropriate biohazard container.

17. Check the patient’s arm and apply a bandage after the bleeding has stopped.

C. Care of the Patient After Phlebotomy:

1. Ask the patient to remain reclining for a few minutes under close observation by staff.

2. Allow the patient to sit up when their condition appears satisfactory. A staff member should

remain with the patient as they assume an upright position.

3. Observe the patient while they have some juice and cookies before allowing the patient to leave.

4. Give the patient instructions about post phlebotomy care.

NOTES:

Orders are to be faxed to the OPTC.

Document all info on Recurring Account form.

PROCEDURES NOTES:

Most donors tolerate giving blood very well, but occasional adverse reactions may occur. It is important to

recognize and start immediate treatment. In general, remove the tourniquet and withdraw the needle from the

arm at the first sign of reaction during the phlebotomy.

A. Fainting-

1. Place the patient on their back and raise his feet above the level of their head.

2. Loosen tight clothing.

3. Be sure the patient has a clear airway.

4. Apply a cold compress to the patient’s forehead or on the back of the neck.

5. Administer ammonia inhalants. Test the ammonia on yourself before passing under the patient’s

THERAPEUTIC PHLEBOTOMY

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nose as it may be too strong.

6. If needed, ask a nurse or physician to check the patient.

B. Nausea and Vomiting-

1. Make the patient as comfortable as possible.

2. Instruct the nauseous patient to breath deeply and slowly.

3. Turn the donor’s head to the side.

4. Apply a cold compress to the patient’s head.

5. Provide an emesis basin or suitable receptacle if the patient vomits, and have cleaning tissues or

damp cloths available. Be sure the patient’s head is turned to the side because of the danger of

aspiration.

6. Give the patient water to rinse out their mouth.

C. Twitching or Muscular Spasms-

1. The common cause of twitching or muscular spasms occurs with the loss of consciousness.

Extremely nervous patients may hyperventilate, causing faint muscular twitching. Diverting the

patient’s attention by engaging in conversation can interrupt the hyperventilation pattern.

However, if symptoms are apparent, call a nurse or physician to help you.

D. Hematoma-

1. Remove the tourniquet and the needle from the patient’s arm.

2. Place 3 or 4 sterile gauze squares over the hematoma and apply firm pressure for 7-10 minutes,

with the patient’s arm held above their heart level.

3. Apply ice to area for 5 minutes if desired.

4. Should an arterial puncture be suspected, immediately withdraw the needle and apply firm

pressure for 10 minutes. Apply pressure bandage afterwards.

5. Check for presence of radial pulse. If the pulse is not palpable, call a physician to help you.

E. Convulsions-

1. True convulsions are rare, but should they occur, call someone to help you immediately.

REFERENCES:

1. AABB Technical Manual, 11th Ed., pp.13-14 and 719-724., Bethesda, MD, 1993.