PROTOCOL FOR VENESECTION Author: Scope: Date: Dr John de Vos All staff who carry out venesection June 2015 (original June 2006 Dr Janet Shirley) Ratified by: Clinical Audit and Effectiveness Committee Review date: June 2018 Contents Page Introduction 2 Polycythaemia Classification Target PCVs for venesection Review 2 2 3 Haemochromatosis 4 Venesection programme 4 References 5 Appendix 1 Venesection Instructions for Doctors and Nurses 6 Appendix 2 Patient Information 7 Appendix 3 Patient Referral to the Nurse-led Venesection Clinic 9 Appendix 4 Venesection Record 10 Protocol for Venesection Author: Dr Janet Shirley Version 2, September 2006 Page 1 of 10
PROTOCOL FOR VENESECTION Introduction Some patients with polycythaemia require regular venesection to keep their blood packed cell volume within specified limits in order to prevent the complications of thrombosis or hyperviscosity. There are different reasons for patients developing a raised PCV and the target for venesection varies according to the exact diagnosis. Another group of patients who require venesection is those with iron overload caused by haemochromatosis. Haemochromatosis is a genetic disorder in which an abnormal gene causes increased absorption of iron from the gastro-intestinal tract. This can lead to iron deposition in the tissues causing abnormal organ function and death. These patients are venesected to bring their ferritin levels down to about 150mcg/ml. Haemochromatosis is managed by the gastro-enterology department who have a designated haemochromatosis clinic. Patients being referred for the nurse led venesection programme should be given a venesection information sheet and sign a consent form. Polycythaemia Classification 1. Apparent erythrocytosis 2. Idiopathic erythrocytosis 3. Primary erythrocytosis (Polycythaemia vera) 4. Secondary erythrocytosis a. Polycythaemia caused by hypoxic pulmonary disease b. Polycythaemia caused by cyanotic congenital heart disease c. Post renal transplant erythrocytosis d. Other renal disease e. High oxygen affinity haemoglobins f. Erythropoietin producing tumour Target PCVs for venesection 1. Apparent Erythrocytosis Confirm the PCV is elevated persistently with at least 2 measurements over a 3 month period. Consider venesection if: i. There is a recent history of thrombosis or the patient has additional risk factors for thrombosis ii. The PCV is >0.56 The target if venesection is indicated is a PCV of <0.45 Protocol for Venesection Author: Dr Janet Shirley Version 2, September 2006 Page 2 of 10
2. Idiopathic Erythrocytosis Venesect if: i. There is a recent history of thrombosis or the patient has additional risk factors for thrombosis ii. The PCV is >0.56 The target if venesection is indicated is a PCV of <0.45 3 Polycythaemia Vera Venesect to maintain the PCV to <0.45 Give aspirin 75mg daily unless contraindicated Consider cytoreductive therapy (usually Hydroxycarbamide) if: o Poor tolerance of venesection o Symptomatic or progressive splenomegaly o Other evidence of disease progression e.g. weight loss, night sweats o Thrombocytosis For patients on Hydroxycarbamide or other cytoreductive therapy arrange consultant review if blood counts drop below normal 4 Hypoxic Pulmonary Disease (HPD) Patients with HPD who develop an erythrocytosis should be evaluated by a respiratory physician for consideration for long-term oxygen therapy or alternative therapy Venesect patients who: o Are symptomatic of hyperviscosity o Have a PCV of >0.56 Venesect to reduce the PCV to 0.50-0.52 5 Cyanotic Congenital Heart Disease These patients are very complex and should be primarily managed in a congenital heart disease unit Isovolumic venesection should be performed when a patient has symptoms of hyperviscosity No general PCV target can be suggested and treatment should be individualised 6 Post Renal Transplant Erythrocytosis Avoid excessive dehydration Venesect patients who: o Are symptomatic of hyperviscosity o Have a PCV of >0.56 If indicated Venesect to a PCV of < 0.45 Protocol for Venesection Author: Dr Janet Shirley Version 2, September 2006 Page 3 of 10
Review Patients with polycythaemia should be routinely reviewed by the relevant consultant in the haematology outpatient clinic every 6-12 months. Haemochromatosis patients are not followed up in the haematology department but in the gastro-enterology department. If they are on cytoreductive therapy they should be reviewed every three months. Patients should also be reviewed if: o They become anaemic (haemoglobin <110g/l for women and <130 g/l for men) o They develop a platelet count or white cell count below normal o They develop new symptoms o Venesection becomes difficult or impossible o They do not tolerate the venesection programme. Haemochromatosis Patients with a diagnosis of haemochromatosis should be venesected to bring their ferritin levels to <150mcg/ml and their iron saturation to normal levels. Haemochromatosis patients are not followed up in the haematology department but in the gastro-enterology department Venesection Programme for polycythaemia patients. Patients should have blood samples taken for FBC (including PCV for those with polycythamia) at every visit. Continue with the venesection if the haemoglobin is normal (>110g/l for women and >130g/l for men) and the PCV is above the target for those patients with polycythaemia Patients should initially be venesected every 1-2 weeks until they reach their target PCV or ferritin level For patients with polycythaemia increase the intervals by 1-2 weeks if the PCV is in or near target. Normally a full bag should be taken (450-500ml). If a patient weighs <50kg it is recommended that only 350-400ml is taken. Protocol for Venesection Author: Dr Janet Shirley Version 2, September 2006 Page 4 of 10
References 1. McMullin M et al, on behalf of the General Haematology Task Force of the British Committee for Standards in Haematology, Guidelines for the Investigation and Management of Polycythaemia/Erythrocytosis, 2005, www.bs-h.org.uk 2. Guidelines for the Blood Transfusion Services in the United Kingdom, 3 rd E. 1996 Protocol for Venesection Author: Dr Janet Shirley Version 2, September 2006 Page 5 of 10
Appendix 1 VENESECTION INSTRUCTIONS FOR DOCTORS AND NURSES Gloves must be worn for this procedure 1. Ask the patient to lie down. 2. Select a large vein in the right or left antecubital fossa. 3. Apply a sphygmomanometer cuff to the upper arm, above the site selected for the venesection. 4. Swab the skin over the selected vein with an antiseptic swab. 5. Offer the patient a local anaesthetic. If the patient does not wish for this proceed to step 7. 6. Draw up a small amount of 1% lidocaine (or equivalent local anaesthetic) into a syringe. (Make sure that you check the labelling and expiry date on the vial.) 7. Insert the syringe needle just below the skin above the vein selected for the venesection and draw back on the syringe to ensure that the needle point is not in a blood vessel. Inject a small amount of lidocaine into the subcutaneous tissue over the vein. Alternatively local anaesthetic cream can be applied over the selected vein. 8. Pump up the sphygmomanometer cuff to 40mm of mercury and keep at this pressure for the duration of the procedure. 9. Insert the needle of the blood pack into the selected vein in the antecubital fossa and secure in place with tape e.g. Micropore. The patient s blood should flow freely into the blood pack. 10. When the blood pack is full, close the clip in the blood pack tubing and let down the sphygmomanometer cuff. 11. Remove the needle from the vein, cover the site with a cotton wool swab and apply firm pressure (the patient can apply the pressure). 12. Dispose of the blood pack, with attached needle covered by the blue needle cover, into a yellow sharps bin with the lid removed (the lid will be attached and sealed at the end of the clinic or when the bin is full). 13. Apply a pressure bandage or cotton wool swab taped firmly in place to the antecubital fossa at the venesection site. Instruct the patient to keep this on until bedtime. 14. Ask the patient to remain lying down for a further 5 minutes and then to get up slowly. Ensure that the patient has a drink before leaving the clinic. Protocol for Venesection Author: Dr Janet Shirley Version 2, September 2006 Page 6 of 10
Appendix 2 VENESECTION CLINIC - PATIENT INFORMATION Your doctor has decided that you need treatment by venesection (blood letting). This procedure is exactly the same as that for donating blood. There are two main reasons for needing treatment by venesection. 1. You have a condition called haemochromatosis which means that you have too much iron stored in your body. Iron is present in red blood cells and with venesection the level of iron is reduced to normal. 2. You have polycythaemia which means that the proportion of red blood cells is increased compared to the fluid content (plasma) of the blood. Venesection will bring this back to normal. With both these conditions you are likely to require repeated venesections. Because you require a regular venesection programme you will be referred to the venesection clinic. This takes place on Wednesday mornings on Chilworth Ward, level F. Your consultant will take your consent for the venesection programme, which will be carried out by specialist nurses. Initially you will need to attend the venesection clinic every 1-2 weeks until your target is reached. Your consultant will explain to you what your target is. Once you have reached your target the interval between venesections will increase and less frequent attendance at the venesection clinic will be required. You will be reviewed by your consultant in the haematology clinic every 3-6 months, or more frequently if this is indicated. Procedure 1. You will have a blood sample taken for a blood count (and iron level if indicated). 2. You will be offered a numbing cream (local anaesthetic). Some people prefer not to have one and you can choose whether you want one or not. 3. When your blood count results are available (this usually takes about 30-45 minutes) the clinic nurse will ask you to lie down on a couch. 4. The nurse will select a vein in the crease of one of your elbows. 5. A blood pressure cuff will be applied to your arm above the elbow crease and pumped up. This is to increase the pressure in the veins in the arm and aid the venesection. 6. The skin over the vein will be cleaned using an antiseptic swab. 7. The nurse will insert the needle attached to the blood pack into your arm and secure it with tape. 8. When the blood pack is full, the clinic nurse will let down the blood pressure cuff, remove the needle and apply a bandage. The bandage should be kept on until bedtime. 9. You will be asked to lie on the couch for a further 5 minutes. Protocol for Venesection Author: Dr Janet Shirley Version 2, September 2006 Page 7 of 10
10. At the end of this time sit up slowly and, when you are sure that you do not feel faint or light-headed, stand up and return to the waiting area. 11. The clinic nurse will give you a drink before you leave. It is important that you have a drink because it replaces some of the fluid in your circulation and prevents you from feeling faint. 12. Providing that you do not feel faint it is safe for you to drive home but please wait at least 15 minutes before doing so. 13. It is advisable not to drink excessive amounts of alcohol or undertake strenuous exercise for the remainder of the day. Most people experience no untoward effects from this procedure. Do not worry if you feel faint the first time this is done. You will find that next time your body adjusts much more quickly and you will be unlikely to feel unwell. Sometimes there will be a little bruising where the needle was inserted. This should fade over a few days. Protocol for Venesection Author: Dr Janet Shirley Version 2, September 2006 Page 8 of 10
Appendix 3 Patient Referral to the Nurse-led Venesection Clinic GP Details: Name: Address: Patient Details: Name: Address: Consultant: DOB: Hospital No. Diagnosis State trigger and target levels according to diagnosis Polycythaemia Haemochromatosis Trigger PCV Target PCV Trigger Ferritin Target Ferritin Medication Aspirin (give dose) Hydroxycarbamide (give dose) Other cytoreductive therapy (give dose) Other medication Review interval for Haematology clinic. Protocol for Venesection Author: Dr Janet Shirley Version 2, September 2006 Page 9 of 10
Appendix 4: Venesection Record Patient Name: Diagnosis Address: Trigger PCV Target PCV Hospital No. DOB: Trigger Ferritin Consultant: GP: Target Ferritin Sheet Number Date 00/00/00 Hb (g/l) WBC x10 9 /L Plats x10 9 /L PCV Ferritin Ug/ml Dr. to Sign here if venesection required Amount venesected (ml) Signature Comments Protocol for Venesection Author: Dr Janet Shirley Version 2, September 2006 Page 10 of 10