The 2006 Infusion Nursing Standards of Practice states, "PICCs, midlines, tunneled catheters, and implanted ports should not be used for therapeutic phlebotomy.” P. S72 What is the reason for this standard and why are nontunneled percutaneous catheters not listed?
The primary reason for not using these catheters for therapeutic phlebotomy is that when this edition of the standards was written there was no published evidence about experience with using them for that purpose. Without evidence, the committee could not make any standards or practice criteria about this practice. Since that time, there may be published evidence now. The actual success rate for this procedure was then and may still be unknown. The standards are in the revisions process now and the committee is taking a hard indepth examination of all published evidence for the entire document.
The concerns for this procedure include the fact that patients in need of therapeutic phlebotomy have very thick, viscous blood flow. This fact coupled with the internal diameter of the catheter in place could reduce the chance of withdrawing the needed volume of blood. It could also shorten the life of the catheter due to attachment of plasma proteins and increasing risk of thrombotic occlusion. The length of these catheters will also add resistance to blood flow, thus increasing the challenge with this procedure. The risk of infection and thrombosis was not known when the current standards were written.
The reason for excluding nontunneled percutaneous central venous catheters was that they are usually not considered for this procedure. Patients requiring this procedure are usually chronic patients, not an acute care patient where the majority of nontunneled percutaneous CVCs are used.
I just did a quick search on PubMed using the search terms "therapeutic phlebotomy" which resulted in over 3000 articles listed. I narrowed the search by using "therapeutic phlebotomy and polycethemia vera". I looked at the titles of 100 articles back to 1998 and none included any indication that the article was about doing the procedure from any type of catheter. For course this simple method is not a complete literature search and some of those articles may contain some information about the procedure. Studies may be published but not indexed on PubMed. But I did not find any articles with the primary purpose of research on using any type of catheter for this procedure. Again another but - I do know that others have successfully done this procedure from implanted ports and tunneled catheters. If the catheter is placed for this purpose, they choose catheters with large internal diameter and use a very large gauge port access needle. The downside to this practice is that the port septum will not last through as many punctures when large gauge needles are used. I also think that the internal diameter of a PICC or midline catheter is far too small to be successful with this procedure.
Sorry I can not be more specific about this topic but we simply need more evidence about clinical outcomes.
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Our dept is considering the practice of doing large volume phlebotomy from central lines including ports. . .we need information badly. . .any help or input is appreciated.
Thanks
While I have never found any published articles about the outcomes of therapeutic phlebotomy from any type of vascular access device, I know it is being done. Also, I have never seen any specific policy or procedure for it either. The best resource of discussion about various clinical experiences would be to go to the IV-therapy website and then do a search for "Therapeutic Phlebotomy". You will find multiple questions posted and some discussion about this procedure from implanted ports.
Thank you for this information. I am just so glad that I found this blog and read that amazing article. It gives me some ideas that I don't know about phlebotomy.
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