Bloodletting: *Is This Archaic Practice Still Being Used?
Examining the current practice of therapeutic phlebotomy. All you need to know as a healthcare provider... no leeches necessary!
Blood letting or venesection was a practice used in many civilizations throughout history including the Egyptians and Romans. It involved the use of lancets, cupping or leeches. In most cases the patient did not experience many benefits but instead became weakened and facing sudden death. “A famous example is that of President George Washington who died in 1799 following the removal of approximately 1.7 litres of blood during a bloodletting procedure for acute epiglottitis.” (Assi & Baz, 2014)
The practice of phlebotomy involves taking a small sample of blood (usually with a small butterfly needle) for laboratory testing. However, therapeutic phlebotomy refers to a less common procedure in which the patient needs a larger amount of blood removed. The specified volume is ordered by a physician/NP. This is done to remove excessive iron or red blood cells in the bloodstream. If left untreated, iron can build up in the heart, liver and joints. Iron overload can cause depression, joint pain, changes in skin color, and even cardiac arrest. Too many red blood cells can lead to thicker blood, potentially causing blood clots to form. The two most common diagnoses needing chronic therapeutic phlebotomy treatment are hemochromatosis (a metabolic disorder in which the body absorbs too much iron) and polycythemia vera (a bone marrow disease leading to excessive production of red blood cells).
Procedure & Supplies
Begin by checking the ordered volume of blood to be removed. In adult care, I have seen large collection bags placed below the patient's midline (using gravity for collection). In pediatric cases many nurses use empty syringes for blood collection. The blood can clot quickly during the process, occluding the IV catheter. Therefore, it is important to have all supplies ready and open to avoid any delay in collection. Here’s a list of the supplies I frequently use when phlebotomizing a pediatric patient:
- One Chux Pad or Sterile Field (place under all supplies for clean work space, also decreases blood splatter)
- Emesis Basin (makes disposal of multiple blood-filled syringes a breeze!)
- Alcohol swabs (for IV site cleansing)
- Empty 10ml syringes (how many depends on volume ordered)
- IV catheter
- Dressing or tape (don’t want to lose that IV site!)
- Laboratory test labels, tubes & transfer device (if any blood tests are also ordered)
- Gauze & Coban (for IV removal upon completion
Tips & Tricks
- Always double check the ordered amount of blood volume for removal against your supplies (For example: If 120ml ordered be sure you only have twelve 10ml syringes in your workspace)
- Using a fresh large bore IV can prevent clotting mid collection (18-20g is preferred, but it is possible to use 22-24g).
- If lab tests are also ordered take the sample from the blood volume already collected, using the last few syringes of blood removed from the patient.
- Be sure to check baseline vital signs before starting collection
- Therapeutic phlebotomy can be a time-consuming procedure. Because this needs to be done with minimal interruption/delay, it can be a great time to chat & connect with your patient. Providing education on adequate hydration prior to their next appointment can assist in a smooth IV placement going forward.
- Check vital signs again once the therapeutic phlebotomy is completed. A slight drop in blood pressure is okay. Your MD/NP should provide parameters for acceptable discharge vitals.
- Dizziness is sometimes a common side effect after a large amount of blood has been removed. Having the patient eat a light snack and drink juice before standing can help.
- Using a light pressure dressing like coban and gauze if preferred over a band aid. It will prevent excessive bleeding post procedure. After all, haven’t we removed enough blood already?!
- High ferritin and iron serum levels should decrease over time with regular therapeutic phlebotomy
Medicine has clearly made significant strides since the time in which bloodletting was an accepted practice. Currently, therapeutic phlebotomy is certainly proven as an effective and precise practice for those who need it. With so many advances constantly happening in the world of medicine, is it possible that physicians years from now will look upon our current practices and consider them archaic as well?
Assi, T. B., & Baz, E. (2014, January 12). Current applications of therapeutic phlebotomy. Retrieved May 18, 2017
What You Don't Know About Excess Iron Could Kill You. Retrieved May 18, 2017
What is Hemochromatosis?Retrieved May 18, 2017
Therapeutic Phlebotomy. Retrieved May 18, 2017Last edit by Joe V on Oct 19, '17
About Ashley Hay, BSN, RN
A freelance healthcare writer with over 10 years of nursing experience in several areas of pediatric & adult oncology including clinical research, chemotherapy, transplant, hematology, proton therapy, GI surgery, wound care, post anesthesia recovery, etc.
Ashley Hay, BSN, RN has '10' year(s) of experience and specializes in 'Oncology'. Joined Aug '16; Posts: 82; Likes: 296.May 20, '17Hello, I have assisted in a few Phlebotomy procedures, and from the patients perspective, it has significantly helped their health. This was on adults only. I find it funny tho that we do this procedure, usually only taking one bag, apx 300-400 Mls, and yet if you donate blood monthly is just called blood donation. Food for thought!May 20, '17The blood letting is not done randomly. There are points used for cupping or hijama. Wet cupping involves using vaccum suction cups, so that only a certain amount of blood is drawn. This practice has historically helped with localized conditions such as gout without overburdening the kidneys or liver for metabolization of impurities. Cupping does not involve opening large veins, only micro circulatory vessels, and therefore is a safer procedure. Problem is, most practitioners are not healthcare providers and the bigges risk is infection.Last edit by feelix on May 20, '17May 20, '17Quote from MelsanMy hospital treats a lot of hematology patients and has it's own blood donation center. Some patients who are being treated for hemochromatosis or PCV and don't have any contraindications are just referred to our donor center on a routine cycle to donate blood.Hello, I have assisted in a few Phlebotomy procedures, and from the patients perspective, it has significantly helped their health. This was on adults only. I find it funny tho that we do this procedure, usually only taking one bag, apx 300-400 Mls, and yet if you donate blood monthly is just called blood donation. Food for thought!May 20, '17That's funny. I (being an old nurse) was just talking to my young coworkers about this the other day. We had a patient whose RBC's were like way high! Of course, they'd never heard of anyone doing this. That's why it's so much fun to be a nurse from the dark ages! The experiences and on-the-job education we got!May 20, '17My biological mother tracked me down when she was diagnosed with hemochromatosis. The treatment for that is basically controlled bloodletting. Ironically, I do not have it, but have the opposite problem: anemia and low iron.
We also do leech therapy on my unit, so old timey stuff does workMay 20, '17Quote from feelixThe blood letting is not done randomly. There are points used for cupping or hijama. Wet cupping involves using vaccum suction cups, so that only a certain amount of blood is drawn. This practice has historically helped with localized conditions such as gout without overburdening the kidneys or liver for metabolization of impurities. Cupping does not involve opening large veins, only micro circulatory vessels, and therefore is a safer procedure. Problem is, most practitioners are not healthcare providers and the bigges risk is infection.
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May 22, '17Our own President George Washingtonp passed away from what he called a sour throat that he had called for blood letting to relieve his pain (according to historical records). Cause of death was epiglottitis and hypovolemic shock...May 23, '17Hhhmmm... (Just a "thinkabout")
Blooddonation is the first I think about. But if you are a transducer ...
But if your cogulationstatus is harmless, the choise between leeches and phlebotomy could be a matter of effort $$$.May 24, '17Mmmm....more study, maybe? Some patients may feel better...others feel "dizzy," or worse. I like to keep an open mind, so I'll allow that in certain, tightly-circumscribed populations this may be an option. But in general it just feels a little, I dunno...creepy. Sorry. Thoughts of far-out pseudo-science pop up when you start talking about blood-letting--it just sounds so primitive.
Of course, the idea of eating nothing but what grows naturally is primitive, too, and the woods are full of people who would totally do exactly that if only they could. And I'm one of them. So, who's to say?
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