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Therapeutic Phlebotomy – Phlebotomy Now School

Therapeutic phlebotomy, also known as therapeutic bleeding, is a medical procedure that removes excess red blood cells or iron from the bloodstream. It’s a safe and effective treatment for various conditions,  improving patients’ quality of life.

Key Takeaways
Therapeutic phlebotomy is a safe and effective procedure that removes excess red blood cells or iron from the bloodstream.
It is primarily used to treat conditions like hemochromatosis, polycythemia vera, and secondary polycythemia.
The procedure involves drawing blood in increments, discarding it, and replacing it with saline solution.
Therapeutic phlebotomy can be repeated at regular intervals to manage chronic conditions.
Benefits include reduced blood clot risk, removal of excess iron, improved symptoms associated with iron overload, and enhanced quality of life for patients.

Who Needs Therapeutic Phlebotomy?

This procedure is primarily used for:

  • Hemochromatosis: A genetic disorder causing iron overload in the body. Excess iron damages organs like the liver, heart, and pancreas.
  • Polycythemia Vera: A bone marrow disease that increases red blood cell production, thickening the blood and raising blood clot risks.
  • Secondary Polycythemia: Similar to polycythemia vera, but caused by another underlying condition like chronic lung disease or congenital heart disease.

Conditions Treated with Therapeutic Phlebotomy

  • Hereditary Hemochromatosis
  • Acquired Iron Overload (from blood transfusions)
  • Polycythemia Vera
  • Other conditions causing erythrocytosis (increased red blood cell count)

What to Expect During Therapeutic Phlebotomy

  • Evaluation: A physician-nurse team assesses your child’s condition to determine the appropriate blood volume for removal.
  • Procedure: Similar to blood donation, a needle is inserted into a vein in your child’s arm. Blood is withdrawn in increments and discarded, with an equal or greater amount of saline solution being infused back into the bloodstream.
  • Duration: The procedure typically takes 1-2 hours, depending on the amount of blood removed.
  • Frequency: Therapeutic phlebotomy may be repeated at regular intervals for conditions like hemochromatosis or polycythemia vera, helping your child manage their condition long-term.

Risks and Side Effects 

Therapeutic phlebotomy is generally safe, but some potential side effects include:

  • Nausea, vomiting, dizziness, or fainting (similar to blood donation)
  • Bruising, numbness, pain, or infection at the needle insertion site

Benefits of Therapeutic Phlebotomy

  • Reduces excess red blood cells, improving blood flow and lowering blood clot risk.
  • Removes excess iron, preventing organ damage from iron overload.
  • Improves symptoms associated with iron overload, such as fatigue, joint pain, and abdominal discomfort.
  • Enhances overall quality of life for patients with chronic conditions requiring phlebotomy.

Understanding Therapeutic Phlebotomy: A Deep Dive

Physiological Mechanism

Phlebotomy stimulates the bone marrow to produce new red blood cells. Iron stores in the body are used for this production, leading to a reduction in overall iron levels.

Treatment Regimen

Factors like age, weight, overall health, and the underlying condition determine the phlebotomy regimen. The following table outlines general guidelines for initiating therapeutic phlebotomy:

Criteria for Initiating Therapeutic Phlebotomy

Patient Group Serum Ferritin (ng/ml)
Children under 18 (regardless of gender) >200
Women (childbearing age, not pregnant) >500
Women (childbearing age, pregnant) >200
Men (over 18) >300

Patient Management and Monitoring

  • Serum Ferritin: The most reliable method for monitoring patients undergoing therapeutic phlebotomy. Frequent monitoring is necessary for patients with very high initial ferritin levels (>1000 ng/ml).
  • Hemoglobin Levels: Checked during each phlebotomy visit. Low pre-phlebotomy hemoglobin (<11 g/dl) may increase the risk of anemia and hypovolemia (decreased blood volume) symptoms.

Phlebotomy Procedure

Therapeutic phlebotomy is performed in a medically supervised setting, typically:

  • Blood donor center
  • Apheresis unit
  • Physician’s office

Prescription for Phlebotomy

A phlebotomy prescription should include:

  • Patient name and diagnosis
  • Date of birth or medical record number
  • Laboratory tests required
  • Amount of blood to be drawn
  • Frequency of phlebotomy
  • Hematocrit parameter
  • Post-phlebotomy care instructions

Phlebotomy Procedure Steps

  1. Pre-procedure Checklist: Blood pressure, pulse, respiration, temperature, hematocrit, arm inspection, and informed consent are obtained.
  2. Preparation: Blood pressure cuff, scale, sterile supplies, and a labeled transfer bag are assembled according to established protocols. The transfer bag is labeled with “Therapeutic Phlebotomy,” patient information, and date. It’s then placed on a scale for monitoring blood draw volume.
  3. Venipuncture: A suitable vein in the arm is selected based on prominence, size, and tone. The area is disinfected according to FDA guidelines. Blood is collected into the transfer bag using a single needle puncture. The average collection time for a unit (500 mL) of blood is less than 10 minutes.
  4. Monitoring Blood Draw Volume: The blood volume drawn is monitored throughout the procedure. Normal blood volume ranges from 477 to 530 grams.
  5. Completion: After collecting the prescribed amount of blood, the following steps are performed:
    1. Clamp the tubing attached to the needle.
    2. Heat-seal the transfer pack tubing three times.
    3. Collect blood samples for laboratory testing (if needed).
    4. Release the blood pressure cuff.
    5. Take post-vital signs.
    6. Remove the needle.
    7. Separate the blood bag and needle at the weld point.
    8. Dispose of the needle and transfer pack in a properly labeled sharps container.
  6. Post-Procedure Monitoring: Observe the patient for any reactions. Notify the appropriate healthcare professional (transfusion service director or primary physician) if any reactions occur. Document the type of reaction and symptom resolution.
  7. Patient Care: Offer refreshments and instruct the patient to wait at least 15 minutes before resuming normal activities.

Allogeneic Use of Collected Blood

There are varying opinions regarding the allogeneic use (use for another person) of blood units collected from therapeutic phlebotomy patients. The United States allows allogeneic use of blood from hemochromatosis patients, but the units must be visibly labeled to indicate the donor’s condition. Blood from patients with polycythemia vera is not used for transfusions due to a potential, though very low, risk of developing leukemia in the recipient.

Conditions Treated with Therapeutic Phlebotomy

While hemochromatosis, polycythemia vera, and secondary polycythemia are the primary conditions using therapeutic phlebotomy, it can also be beneficial for:

  • Porphyria cutanea tarda: This rare disorder causes painful, blistering skin lesions on sun-exposed areas. Therapeutic phlebotomy can help reduce symptoms by lowering iron levels.
  • Sickle cell disease: This genetic blood disorder can lead to complications like organ damage and stroke. Phlebotomy can help manage the condition by decreasing the number of red blood cells, improving blood flow.

Alternatives to Therapeutic Phlebotomy

In some cases, therapeutic phlebotomy may not be the best course of treatment. Alternative options include:

  • Chelation therapy: Medications called chelators bind to excess iron in the bloodstream, allowing it to be eliminated through urine.
  • Iron restriction therapy: Dietary changes and avoiding iron supplements can help manage iron overload in some cases.

Risks and Complications of Therapeutic Phlebotomy

Therapeutic phlebotomy is generally safe, but there are potential risks to consider:

  • Infection: Proper needle handling and aseptic technique minimize this risk.
  • Hematoma (bruising): Applying pressure to the insertion site after the procedure can help reduce bruising.
  • Lightheadedness and Fainting: These are common side effects that usually resolve quickly. Staying hydrated and lying down for a few minutes after the procedure can help.
  • Allergic reaction: This is rare, but some people may be allergic to medications or materials used during phlebotomy.
  • Excessive bleeding: Pressure is applied to the insertion site after the needle is removed to minimize this risk.
  • Low blood pressure: Drinking plenty of fluids before and after the procedure can help maintain blood pressure.
  • Deep vein thrombosis (DVT): This is a serious condition where a blood clot forms in a deep vein, usually in the leg. Maintaining good hydration and moving your legs regularly can help reduce the risk.

Benefits of Therapeutic Phlebotomy

Beyond reducing blood clot risk and improving blood flow (already mentioned), therapeutic phlebotomy offers several other benefits:

  • Increased energy levels: By lowering iron overload, phlebotomy can improve fatigue, a common symptom.
  • Reduced joint pain: Excess iron deposits can cause joint pain. Phlebotomy can help alleviate this discomfort.
  • Improved liver function: Iron overload can damage the liver. Regular phlebotomy can help protect liver function.

Preparing for Therapeutic Phlebotomy

Here’s what to do to prepare for your therapeutic phlebotomy appointment:

  • Eat and drink normally: There are usually no restrictions on food or drink before phlebotomy. However, staying hydrated is important.
  • Wear comfortable clothing with easy access to the arm where the blood will be drawn.
  • Tell your doctor about any medications you’re taking. Some medications may need to be adjusted before phlebotomy.

Recovery after Therapeutic Phlebotomy

After your therapeutic phlebotomy:

  • Expect mild discomfort at the needle insertion site. Applying a cold compress can help reduce swelling.
  • Drink plenty of fluids to help replace lost fluids.
  • Avoid strenuous activity for a few hours.
  • Monitor the insertion site for signs of infection, such as redness, swelling, or pus.

If you experience any concerning side effects after your phlebotomy, contact your doctor immediately.

Therapeutic Phlebotomy: Beyond Blood Draws

Therapeutic phlebotomy, a procedure that removes excess blood to treat certain medical conditions, is a safe and effective tool. However, it’s not the only option. Let’s explore some alternatives, additional treatable conditions, and clarify its distinction from a historical practice.

Alternatives to Therapeutic Phlebotomy:

  • Chelation therapy: This treatment uses medications called chelators to bind iron in the bloodstream. The chelator-iron complex is then excreted through urine. While effective, chelation therapy can have side effects and requires close monitoring by a healthcare provider.

  • Iron restriction therapy: This approach aims to limit iron absorption from the diet. It involves dietary changes, like avoiding iron-fortified foods and supplements, and may include medications that decrease iron uptake in the intestines.

Conditions that Benefit from Therapeutic Phlebotomy:

  • Hemochromatosis: This genetic disorder causes iron overload in the body.
  • Polycythemia vera: A bone marrow disorder leading to an excess of red blood cells, increasing blood viscosity and clotting risk.
  • Secondary polycythemia: Similar to polycythemia vera, but caused by underlying conditions like sleep apnea or high-altitude living.
  • Porphyria cutanea tarda (PCT): A rare skin disorder where excess iron can worsen symptoms like skin blistering.
  • Sickle cell disease: In some cases, therapeutic phlebotomy can help reduce complications by lowering red blood cell count and blood viscosity.

Therapeutic Phlebotomy vs. Bloodletting:

Therapeutic phlebotomy is a controlled medical procedure performed by trained phlebotomists using sterile needles and following strict guidelines. The amount of blood removed is carefully measured to achieve the desired therapeutic effect.

Bloodletting, a historical practice dating back centuries, involved removing blood for various ailments with the belief of restoring balance in bodily fluids. However, bloodletting lacked scientific basis and often did more harm than good.

Who Performs Therapeutic Phlebotomy?

Trained phlebotomists with proper certifications perform therapeutic phlebotomy. They are skilled in venipuncture (drawing blood from a vein) and ensure patient safety and comfort throughout the procedure.

By understanding these additional aspects of therapeutic phlebotomy, you can have a more informed discussion with your doctor about the best course of treatment for your specific condition.


Therapeutic phlebotomy is a safe and effective procedure for managing iron overload and reducing excess red blood cells in various medical conditions. By understanding the benefits, risks, and what to expect during and after the procedure, you can make informed decisions about your healthcare.


Who can benefit from therapeutic phlebotomy?

People with hemochromatosis, polycythemia vera, or other conditions causing an excess of red blood cells or iron overload may benefit from this procedure.

What are the risks of therapeutic phlebotomy?

Therapeutic phlebotomy is generally safe, but potential side effects include nausea, vomiting, dizziness, fainting, bruising, numbness, pain, or infection at the needle insertion site.

How often is therapeutic phlebotomy performed?

The frequency depends on the underlying condition and the amount of blood removed. It can range from weekly to monthly intervals.

Can the blood removed during therapeutic phlebotomy be used for transfusions?

In some cases, yes. Blood from hemochromatosis patients can be used for transfusions with proper labeling. However, blood from polycythemia vera patients is not typically used due to a low risk of leukemia transmission.

Where is therapeutic phlebotomy performed?

This procedure is typically performed in a medically supervised setting like a blood donor center, apheresis unit, or a physician’s office.

What qualifications are needed to perform therapeutic phlebotomy?

Trained phlebotomists with proper certifications can perform therapeutic phlebotomy.

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By understanding the role of therapeutic phlebotomy and its benefits, healthcare professionals can provide optimal care for patients with iron overload and related blood disorders.

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