History 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) Current Practice 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!) Tourniquet 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. Post Care 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? References: 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, 2017