Phlebotomy is the process of making a puncture in a vein, usually in the arm, with a cannula for the purpose of drawing blood. The procedure itself is known as a venipuncture, which is also used for intravenous therapy.
Phlebotomy, which used to be known as bloodletting, has been used for centuries, with its origins traced back to Greece. It was used for both curative as well as preventative treatments.[1] These practices at the time were neither regulated nor properly understood as it is in the 21st century. It was thought that any disease or sickness was due to an imbalance of various fluids in the body, and bloodletting would be a way of restoring that balance.[2] As a result, the practice of bloodletting often led to poor clinical outcomes. A prime example was the death of George Washington (1st president of the United States), who died after losing blood as a treatment for acute epiglottitis.[3]
Over time, phlebotomy has evolved to be an extremely crucial diagnostic as well as therapeutic solution. Today, phlebotomy is used constantly in clinical environments to increase the understanding of a patient's clinical presentation and concurrently improve the clinical outcomes of patients. The scope of this review will be to discover the modern understanding of what phlebotomy is, such as the best anatomical sites for drawing blood, equipment needed, and the proper technique. This review will also cover the indications and contraindications as well as any potential complications.
When drawing blood, it is important to prioritize the efficiency of the draw and the overall comfort of the patient. Thus, drawing blood from veins is preferred compared to arteries. This is because veins run superficially. Furthermore, arteries tend to have thicker walls and have more nerves associated with them, resulting in increased pain should they be punctured. Therefore, arterial blood sampling would be indicated for gathering data on arterial blood gases.
The common location for a blood draw is in the medial cubital fossa. In this area, the medial cubital vein is superficial and covers the bicipital aponeurosis in the cubital fossa.[4] Many anatomical variants are possible. The median cubital vein is the most common choice because of the thick walls that can tolerate the negative pressures when drawing blood.[5]
This is in contrast to the dorsum of the hand, which is the preferred location for establishing an IV site. It is extremely critical to distinguish the median cubital vein from the basilic vein, medial along the arm. Extra precaution when drawing blood from the basilic vein is necessary because it runs with the artery and nerve. A puncture here can be extremely painful and uncomfortable for the patient. Severing the medial antebrachial cutaneous nerve near the basilic vein results in loss of sensation to the skin of the medial forearm.
Other common locations for blood draws include the lateral plantar surface of the heel in an infant and the cephalic and basilic vein in the cubital fossa.
The indications for phlebotomy can be numerous. For simplicity and effective organization, this review will distinguish the clinical scenarios into diagnostic and therapeutic.
Diagnostic
There are endless medical conditions that can be diagnosed based on results from a blood draw. Listed are a few ways to acquire information from analyzing blood.
Laboratory values: bilirubin, which is a breakdown product of red blood cells, circulates in the bloodstream in two forms - conjugated and unconjugated.[6] A blood sample from a heel poke hours after birth or after a high degree of clinical suspicion will reveal bilirubin levels to determine an appropriate course of action for treatment. Blood draws can also be extremely useful for establishing a differential when anemia is suspected. This is because of the various laboratory values it can provide. Values such as mean corpuscular volume, lactate dehydrogenase, reticulocyte count, and haptoglobin levels are a few of many that can help distinguish a variety of types of anemias for a seemingly similar clinical presentation.[7] Furthermore, blood testing can be critical for diagnosing pathologies of the heart, such as myocardial infarction.[8] Cardiac enzymes can be released into the bloodstream signifying damage to the heart. Appropriate analysis can result in swift clinical action and improved clinical outcomes.
Peripheral blood smear (PBS): Peripheral blood smears are essential in the diagnosis of anemia. By analyzing a thin layer of blood under a microscope, accurate analysis of RBC shape, color, size, and other morphologies can help establish a differential for the various causes of why a patient can be anemic.[9] Evidence suggests that a peripheral blood smear analysis can be more accurate in diagnosing sickle cell disease than other methods.[10] A peripheral blood smear can also aid in the diagnosis of disordered affecting platelet quantity and morphology.[11] Additionally, leukocytosis is prevalent in peripheral blood smear analysis requiring further workup to determine if the finding is incidental or results from a malignant cause such as leukemia.[12]
Therapeutic
Therapeutic phlebotomy is the practice of bloodletting passed down through generations. It is beneficial for certain conditions where removing red blood cells or serum iron improves clinical outcomes.[13] It is important to understand what these conditions are.
Polycythemia Vera: Polycythemia vera is a myeloproliferative disorder resulting in the excess production of red blood cells. Symptoms of this disorder, such as plethora, splenomegaly, pruritus after showering, and redness, are due to the hyperviscosity of the blood predisposing patients to thrombosis.[14] Diagnosis can be made through elevated red blood cell mass on blood analysis. Therapeutic phlebotomy is the primary treatment of choice for Polycythemia Vera and results in improved symptoms and clinical outcomes by reducing the overall quantity of blood. It is important to note that certain pathologies can increase blood-red cell mass; these are deemed as secondary polycythemia, and phlebotomy may not be an appropriate treatment for these conditions.
Hemochromatosis: Hemochromatosis refers to a condition of iron overload. The human body does not have the ability to get rid of iron in any amount of significance. In this condition, there is an irregular absorption of iron due to gene mutations resulting in excessive buildup.[15] Excessive iron buildup can lead to multiple organ failures, including the heart, pancreas, and liver. Therapeutic phlebotomy is the treatment of choice. Removing blood is the most effective way of reducing iron levels in the body. Patients afflicted with this condition necessitate regular periodic phlebotomy treatments to keep iron levels in a healthy range.[13]
Porphyria: Porphyria encompasses a list of conditions that involve the disruption of heme synthesis. Hemoglobin can be broken down into heme, the iron carrying component, and globin chains. Heme is a porphyrin ring that holds an iron ion. Each type of porphyria is associated with a specific enzyme deficiency in the heme synthesis pathway. While the list of conditions has varying symptoms, it is thought that the production of certain enzymes in the heme synthesis pathway is inhibited by the body's own iron. Thus, research shows that phlebotomy is an excellent treatment option by reducing iron stores.[16]
Various other conditions have been linked with phlebotomy as an appropriate treatment option. These include Hemoglobin SC disease due to the reduction in blood viscosity and sickle cell disease resulting in a potential decrease in the frequency of vaso-occlusive crisis events.[17][18] These conditions require additional research and trials before being accepted as appropriate treatments, but initial trials show potential for improved clinical outcomes.
Some contraindications to drawing blood can be specific to the location of the blood draw or the overall condition itself. Studies suggest that phlebotomy can be an inappropriate treatment for non-hereditary mutation association etiologies of hyperferritinemia leading to complications such as iron deficiency anemia and fatigue.[19]
In terms of location, previously attempted sites with residual scar tissue are a contraindication. Conditions such as cellulitis or an abscess can increase the risk of bacteria directly infiltrating the blood. Other contraindications for phlebotomy procedures include the presence of a vascular graft, a hematoma, venous fibrosis on palpation, a history of ipsilateral radical mastectomy, and any device used for venous access such as a venous port, central catheter, or an intravenous catheter.[5] A thorough investigation of the patient's medical history will be necessary to minimize complications from a blood draw.
Source: www.ncbi.nlm.nih.gov/
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Disclosure: Kishan Srikanth declares no relevant financial relationships with ineligible companies.
Disclosure: Saran Lotfollahzadeh declares no relevant financial relationships with ineligible companies.