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