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PubMed1992

Treatment of proximal aortic hypertension after thoracic aortic cross-clamping in dogs. Phlebotomy versus sodium nitroprusside/isoflurane.

Thoracic aortic cross-clamping causes proximal aortic hypertension. Theoretically, the method used to treat hypertension can influence spinal cord perfusion pressure and neurologic outcome. Phlebotomy was compared to sodium nitroprusside/isoflurane in terms of ability to treat increased proximal mean aortic pressure (MAPp) after thoracic aortic cross-clamping in dogs. Dogs were assigned randomly to one of three groups depending on the method used to treat hypertension after cross clamping: 1) phlebotomy (n = 10); 2) sodium nitroprusside/isoflurane (n = 11); and 3) control (no treatment) (n = 8). In each dog, anesthesia was maintained with isoflurane in oxygen, 1.4% end-tidal. The thoracic aorta was occluded 2.5 cm distal to the left subclavian artery for 50 min and then was released. Hemodynamics, cerebrospinal fluid pressure (CSFP), and regional blood flows by the radioactive microsphere technique, were measured at 1) baseline; 2) 2 min after aortic cross-clamping; 3) after treatment of proximal aortic hypertension; 4) 5 min after aortic unclamping; and 5) 30 min after resuscitation. At 24 h, a neurologic assessment was performed. Thoracic aortic cross-clamping increased MAPp, decreased distal MAP (MAPd), and reduced lumbar spinal cord perfusion pressure (SCPPl), [SCPPl = MAPd - CSFP], in all three groups. Control of increased MAPp necessitated removal of 36 +/- 9 ml/kg of blood in the phlebotomy group. In the sodium nitroprusside/isoflurane group, sodium nitroprusside (16 micrograms.kg-1.min-1) was infused and end-tidal isoflurane concentration increased to 2.5 +/- 0.7%, restoring MAPp to baseline level.(ABSTRACT TRUNCATED AT 250 WORDS)

Animals↗
PubMed1986

Iron removal therapy in porphyria cutanea tarda: phlebotomy versus slow subcutaneous desferrioxamine infusion.

Twenty-five patients with overt clinical and biochemical findings of porphyria cutanea tarda took part in a study comparing intensive phlebotomy with slow subcutaneous desferrioxamine treatment. Fifteen male patients (Group A) had intensive venesection therapy. Ten patients (Group B) with associated diseases (minor thalassemia, cardiovascular impairment, pulmonary tuberculosis or severe liver cirrhosis) received 1.5 g of desferrioxamine by slow subcutaneous infusion using an automatic syringe pump 5 days a week. No patient complained of appreciable side effects. Serum iron, ferritin and uroporphyrins were normalized in all subjects by the end of treatment. The mean time necessary for complete recovery was 13.8 months (range 9-19) and 11.2 months (range 6-14) in Groups A and B, respectively. Liver function significantly improved during and after the treatments in both groups. We conclude that recovery from porphyria cutanea tarda can be achieved equally well using phlebotomy or desferrioxamine subcutaneous infusion. Phlebotomy is easily performed and remains the treatment of choice; slow subcutaneous desferrioxamine treatment, although expensive, is recommended when severe associated diseases contra-indicate venesection.

Adult↗
PubMed1978

Serum ferritin levels in male blood donors: relation to number of phlebotomies and iron supplementation.

Serum ferritin estimation has been shown to be a reliable test to reveal iron deficiency. Such estimations have been made in groups of male blood donors with a varying number of previous phlebotomies and a mean interval between donations of 9.9 +/- 1.7 SD weeks. It was found that the mean ferritin level was significantly (p less than 0.001) lower in the blood donors than in nondonors. After 6-8 phlebotomies it was about 40% lower. Subnormal ferritin values were found in 10% of the donors, almost exclusively among those who had taken less than 1,000 mg of iron supplementation since the last donation. It is concluded that with a donation interval of about 10 weeks, there is a considerable risk for iron deficiency after about 6 donations. This risk is far less if more than 1,000 mg of iron supplementation is taken between phlebotomies. A role for serum ferritin estimation in monitoring donation intervals and/or iron therapy is suggested.

Anemia, Hypochromic↗
PubMed1986

Integrated image and X-ray microanalysis of hepatic lysosomes in a patient with idiopathic hemosiderosis before and after treatment by phlebotomy.

Morphometrical and X-ray elemental information was extracted from Scanning Transmission Electron Microscopy (STEM) images of hepatic lysosomes of a patient with idiopathic hemosiderosis before and after treatment by phlebotomy. The elements of interest were iron, stored in pathological quantities in hepatic lysosomal structures and cerium, used as a capture ion after a cytochemical reaction to detect acid phosphatase activity in the lysosomal structures. Morphologically the lysosomal structures are heteromorph and the elements iron and cerium are heterogeneously distributed. With "reduced raster" (= reduced scanning area) analysis at 16 X 16 pixelpoints (integrating image and X-ray microanalysis), a marked difference in the area of the cross sectioned lysosomal structures before and after treatment could be demonstrated. Simultaneously the difference in the relative orientation of the elements iron and cerium before and after phlebotomy could be visualized. Chelex ion exchange beads, loaded with 11.5% w/w iron, and coembedded with the tissue blocks, were used as an internal standard. A mean iron peak to background ratio was obtained and a factor, converting ratio to absolute iron concentration, was calculated. The same calculation procedure, now per pixelpoint, was followed for the hepatic lysosomal structures. A marked difference in iron concentration in the individual lysosomal structures was observed before and after treatment by phlebotomy.

Bloodletting↗
PubMed1994

Improvement of serum aminotransferase levels after phlebotomy in patients with chronic active hepatitis C and excess hepatic iron.

OBJECTIVES: Iron metabolism may be altered in patients with chronic active hepatitis C. In an attempt to evaluate whether excess iron contributes to liver injury, we used phlebotomy for removal of iron from patients with chronic hepatitis C. METHODS: All 10 patients had histochemically detectable iron in the liver and underwent an initial period of weekly or monthly phlebotomy of 200 or 400 ml. A serum ferritin level of 10 ng/ml or less was chosen as the endpoint, and maintenance phlebotomy was performed if the level rebounded. RESULTS: The treatment reduced mean serum alanine aminotransferase activity from 152 +/- 49 to 55 +/- 32 IU/L; this level became normal in five of the 10 patients. Anti-HCV antibodies could be detected in all patients throughout the study. Histologic abnormalities of the liver were unchanged except for disappearance of iron deposits from seven of the patients studied. CONCLUSIONS: Our findings suggest that iron removal may be beneficial for patients with chronic active hepatitis C and histochemical iron in the liver.

Adult↗
PubMed1976

How phlebotomy affects the erythrocyte metabolism of high- and low-glutathione sheep.

Erythrocyte glutathione concentration increases dramatically in low-glutathione sheep of the Finnish-Landrace breed. To determine if this phenomenon occurs in low-glutathione sheep of the Corriedale or Merino type, the packed cell volume was decreased to less than 16 by phlebotomy. Glutathione concentrations increased in high- and low-glutathione sheep. Low-glutathione sheep returned to pre-phlebotomy levels by the 18th day; high-glutathione sheep increased, then decreased below pre-phlebotomy levels for the duration of the experiment. Packed cell volumes increased linearly (1-07 per cent per day) for 19 days. The maximum reticulocyte percentage (11-4) occurred on the eight day. Some erythrocyte enzymes increased as the mean cell age decreased, but some did not change. Erythrocyte adenosine-5'-triphosphate and creatine appear to be related to the reticulocyte count.

Animals↗
PubMed1976

Hazards of phlebotomy in polycythemic patients with cardiovascular disease.

Three patients with polycythemia and previous evidence of cardiovascular disease underwent routine phlebotomies. Systolic hypotension followed by ineffective volume replacement with electrolyte solutions developed in all patients after phlebotomy. In two patients acute myocardial infarction and in a third cardiovascular collapse and death were temporally related to the procedure. This experience suggests that phlebotomy in patients with cardiovascular disease should be performed by the slow removal of small volumes of blood under continuous blood pressure monitoring. Effective restoration of the plasma volume with plasma or colloid is essential unless volume overload is present.

Acute Disease↗
PubMed2000

Iron deficiency due to excessive therapeutic phlebotomy in hemochromatosis.

Thirteen adults (eight men, five women) with hemochromatosis had undergone routine iron depletion therapy but while on maintenance phlebotomies developed iron deficiency which persisted for 25 +/- 13 (mean +/- 1 SD) months before diagnosis. All had symptoms and signs of iron deficiency. Levels of transferrin saturation were 10% +/- 5% (1 SD), and serum ferritin concentrations were 8 +/- 3 ng/mL. Eleven had anemia; eight had hypochromia and microcytosis. Bone marrow specimens obtained in five patients revealed no stainable iron. Medical records indicated that parameters of body iron status were infrequently or incorrectly used for adjusting the frequency of phlebotomies. Two patients developed iron deficiency due to additional blood loss from esophageal varices and bilateral hip replacement, respectively. Ten of the patients were treated with ferrous sulfate, 325 mg daily, for 2-6 weeks when anemia was corrected. In patients who were not given iron, anemia and microcytosis recovered in 8-24 months. We conclude that (i) sustained iron deficiency in hemochromatosis patients should be prevented by monitoring hemoglobin levels and serum ferritin; and (ii) hemoglobin concentrations and values of mean corpuscular hemoglobin may be higher in iron-deficient persons with hemochromatosis than in individuals without hemochromatosis. Symptomatic iron deficiency in hemochromatosis patients may be treated safely with a brief course of ferrous sulfate. Recovery is slower when iron is not given. However, iron supplementation is unnecessary and not recommended for the mild, self-limited anemia and decreased serum iron and ferritin concentrations encountered after initial iron depletion therapy for hemochromatosis.

Adult↗
PubMed1998

Four indefensible phlebotomy errors and how to prevent them.

The author identifies four errors in phlebotomy that are effectively indefensible in a court of law: patient misidentification, improper angle of insertion, improper vein selection, and ineffective training and evaluation of those performing venipunctures. Strategies to avoid these errors include the implementation and enforcement of specific administrative and procedural policies. A side bar on the "Ten Commandments of Phlebotomy Liability" accompanies this article.

Clinical Competence↗
PubMed2006

Fear of needles and vasovagal reactions among phlebotomy patients.

Anxiety associated with blood and injections is a common problem in medical settings and, in severe cases, affects sufferers' ability to receive medically essential treatment. The present study was conducted to examine incidence of adverse reactions to venipunctures among phlebotomy patients, as well as to understand the demographic and psychological characteristics associated with such reactions. A large sample of participants undergoing venipuncture (N=3315) was recruited from hospital-based phlebotomy laboratories. Participants completed a brief questionnaire assessing psychological and physiological reactions to having their blood drawn. Results indicated that a small minority of patients experienced significant anxiety symptoms during venipuncture. Vasovagal reactions and vasovagal syncope were extremely infrequent. A tendency to experience pain, disgust, and fear of fainting during injections was associated with anxious responding to the venipuncture and a probable diagnosis of needle phobia. Theoretical and practical implications are discussed.

Adult↗
PubMed2006

Femoral phlebotomy: the vacuum tube method is preferable over needle syringe.

A syringe needle (SN) is commonly used to obtain blood specimens from the femoral vein. The vacuum tube (VT) method avoids the needle stick potential of the SN technique during transfer of blood from the syringe to the collection tubes. We compared the perceived safety, patient pain, and efficacy of SN and VT for femoral phlebotomy in a prospective trial. Of 64 patients entered, 38 (59%) had the VT technique and 26 (41%) had the SN technique. There was no significant difference in the success rate between VT and SN (100% vs. 95%, respectively). The VT method was somewhat faster than the SN method (104 +/- 109 vs. 181 +/- 149 s, respectively, p = 0.06). Complications were infrequent and not different between the groups. The mean patient pain score +/- SD on a 10-cm visual analog scale for the VT and SN techniques were 2.6 +/- 2.2 and 3.7 +/- 2.7, respectively (p < 0.001). Physicians subjectively rated the safety of the procedure higher for the VT method than for the SN method. Medical personnel should consider use of the VT method instead of the traditional SN technique for femoral phlebotomy.

Adult↗
PubMed2006

Reducing the potential for phlebotomy tourniquets to act as a reservoir for meticillin-resistant Staphylococcus aureus.

The contamination rate of phlebotomy tourniquets with meticillin-resistant Staphylococcus aureus (MRSA) was assessed, and it was determined whether this could be reduced by changes in practice or by the use of a physical barrier. Initially, the tourniquets of both preregistration house officers and phlebotomists were investigated, but as phlebotomists reported significantly more venepunctures daily, the trial continued solely with phlebotomists. Each day, the phlebotomists were supplied with a fresh sterile tourniquet, and after use, the tourniquets were swabbed and cultured. The rate of contamination with MRSA was 32 of 131 (25%) tourniquets. An audit of hand hygiene practice was undertaken and revealed that phlebotomists were performing hand decontamination inadequately between patients and wore wristwatches while working. Education comprising standard infection control methods to encourage good practice was given. After this, a polythene strip was used as a barrier by half of the phlebotomists during all venepunctures. Tourniquets were cultured and replaced daily as before. During this stage of the trial, the rates of contamination were 1 of 46 tourniquets (using a polythene strip) and 1 of 42 tourniquets (without using a polythene strip). In conclusion, phlebotomy tourniquets may be potential vectors for transferring bacteria, including MRSA. Contamination rates, and hence potential risk, can be reduced if hand decontamination is performed. This suggests that contamination of tourniquets is via phlebotomists' hands, not directly from patients' skin. Hand hygiene should be regarded as the most important method by which the spread of organisms can be reduced.

Cross Infection↗
PubMed2004

[Porphyria cutanea tarda in a hemodialysed patient with hepatitis C virus infection: efficacy treatment by small repeated phlebotomies].

INTRODUCTION: Porphyria cutanea tarda (PCT) is a disorder of heme biosynthesis resulting from deficiency in the enzyme uroporphyrinogen decarboxylase. In the sporadic form of PCT, there are many agents that trigger the clinical manifestations. EXEGESIS: We report a case of PCT in an hemodialysed patient with hepatitis C virus infection (HVC). He was treated with small repeated phlebotomies of 50 ml every week with photoprotection, eviction of traumatismes and inducing drugs. A clinical remission was induced after five months of treatment. CONCLUSION: A proper diagnosis of PCT in non uremic hemodialysed patients requires fractionation of serum and fecal porphyrin changes. Management of this patients is difficult. Small repeated phlebotomies (50-100 ml) could be an interesting therapy.

Aged↗
PubMed1997

Hepatic stellate cell activation in genetic haemochromatosis. Lobular distribution, effect of increasing hepatic iron and response to phlebotomy.

BACKGROUND/AIMS: Activated hepatic stellate cells produce increased levels of collagen in animal models of chronic iron overload; however, their role in human genetic haemochromatosis is unknown. This study examined the relationship between hepatic iron concentration and hepatic stellate cell activation in genetic haemochromatosis. METHODS: Liver biopsies from 75 patients (55 with haemochromatosis, 14 haemochromatosis patients both pre- and post-phlebotomy and six non iron-loaded disease control subjects) were stained for iron using Perls' Prussian Blue. Thirty biopsies in which there was no evidence of either steatosis or inflammation were subjected to immunohistochemistry for alpha-smooth muscle actin and desmin and counterstained for iron. Forty-five biopsies demonstrated either steatosis or inflammation, in addition to excess iron. RESULTS: Stellate cells were identified by light microscopy as perisinusoidal cells containing numerous intracellular fat droplets. alpha-Smooth muscle actin was detected in biopsies with an hepatic iron concentration >60 micromol/g dry weight. Increasing hepatic iron concentration and hepatic iron index correlated with an increase in alpha-smooth muscle actin expression (r=0.81 and 0.72, respectively). Phlebotomy resulted in a significant decrease in alpha-smooth muscle actin expression. In early disease prior to histological evidence of collagen deposition, whilst activated stellate cells were located in Zone 1, greater numbers were found in Zones 2 and 3 distal to the region of heaviest iron overload. CONCLUSIONS: This study has demonstrated for the first time in humans a correlation between hepatic iron concentration and stellate cell activation in haemochromatosis, which is reversed by iron removal. Humoral factors from either iron-loaded hepatocytes or activated Kupffer cells may be responsible for early stellate cell activation in areas of the liver remote from heavy iron loading.

Actins↗
PubMed1999

Iron depletion by phlebotomy with recombinant erythropoietin prior to allogeneic transplantation to prevent liver toxicity.

Iron overload may induce liver toxicity after hematopoietic stem cell transplantation (HSCT), but it is not known if iron depletion prior to HSCT can reduce the risk of severe toxicity in this setting. We used subcutaneous recombinant erythropoietin (EPO) (25 UI/kg) three times a week and phlebotomy once a week, to prevent liver toxicity in a patient with advanced acute leukemia and liver disease due to severe iron overload, previous drug toxicity and hepatitis C viral infection. Over the 9 months prior to allogeneic HSCT, 34 phlebotomies were carried out. Serum ferritin dropped from 2964 to 239 microg/l and the ALT dropped to near normal values. At allogeneic HSCT no liver toxicity was observed, suggesting that iron depletion in the pretransplant period may contribute to reducing transplant-related toxicity in selected cases.

Adult↗
PubMed2001

Arterial puncture phlebotomy in whole-blood donors.

BACKGROUND: An arterial puncture during whole-blood phlebotomy is a rare event. A series of arterial punctures was evaluated to determine the clinical findings and the incidence of complications. STUDY DESIGN AND METHODS: Arterial punctures reported by staff between January 1, 1999, and February 28, 2001, were evaluated. Follow-up interviews were done with the phlebotomy nurses to determine what the clinical findings were and what the incidence of complications was. RESULTS: Twelve cases of arterial punctures were identified from 410,000 blood donations (0.0029%; 1/34,000). Eleven cases had a fast blood-flow rate of <4 minutes; 9 units (75%) were bright red; and in 4 cases (33%), the needle was pulsating. One case was diagnosed because the donor developed a brachial artery pseudoaneurysm 3 days after donation. Four hematomas occurred, for an occurence rate of 33 percent (0.35% in the general donor population). There was also an association with newly trained staff. CONCLUSION: Fast blood-flow rate is the most common clinical feature after an arterial puncture. Bright red blood is usually, but not always, present, and a pulsating needle is sometimes present. Hematoma is a relatively common complication, and brachial artery pseudoaneurysms are rare, although one case was seen in this study.

Adult↗
PubMed1997

Recovery of pancreatic beta-cell function in hemochromatosis: combined treatment with recombinant human erythropoietin and phlebotomy.

A patient with diabetes mellitus caused by secondary hemochromatosis was treated using recombinant human erythropoietin and phlebotomy. A total of 12 g of iron had been infused in the patient because of iron deficiency anemia. Blood glucose level was 17.3 mmol/L, and hemoglobin A1c level was 9.0% at admission. He was treated using phlebotomy (400 mL per week), along with subcutaneous injection of 3,000 U of recombinant human erythropoietin three times a week. After approximately 100 days, a total of 5,500 mL of blood (2.75 g iron) could be removed. Serum ferritin level decreased from 10,000 micrograms/L to 4,807 micrograms/L. Fasting and maximum serum C-peptide immunoreactivity values during 100-g oral glucose tolerance tests were improved from 0.14 nmol/L to 0.42 nmol/L and from 1.84 nmol/L to 2.61 nmol/L, respectively. This case suggests that pancreatic beta-cell recovers in diabetes caused by hemochromatosis by reducing iron overload during a short period.

Aged↗
PubMed1996

EMLA cream as a topical anesthetic before office phlebotomy in children.

We studied the effectiveness of EMLA cream (2.5% lidocaine, 2.5% prilocaine) in reducing distress, anxiety, and pain associated with phlebotomy in pediatric outpatients. This was a randomized, double-blind, placebo-controlled study using EMLA cream or placebo 1 hour before phlebotomy. Distress, anticipatory anxiety, pain, and adverse reactions were measured. Measurements of distress and ease of procedure, as well as changes in heart rate, showed significant improvement with EMLA cream as compared with placebo. Pain was decreased with use of EMLA cream. Anticipatory anxiety levels were equal within both groups. Ratings of cream efficacy by parent/observer scales were in favor of EMLA cream.

Adolescent↗