Clinical Protocols

| Endocarditis | Phlebotomy |

Phlebotomy

There are two indications for phlebotomy.

- the occurrence of symptomatic iron-replete hyperviscosity

Erythrocytosis of Cyanotic Congenital Heart Disease
Hct > 65%				Hct < 65%
Hyperviscosity				Hyperviscosity
No	Yes			Yes	No
Observe	Dehydration?		->	Iron defieciency?	Observe
	Yes	No		Yes
	Volume replacement	Phlebotomy		Iron replacement

- the prevention of excessive bleeding in perioperative management, discussed below.

Bleeding tendency
Spontaneous			Perioperative
mild	serious		Measure Hb, Plts, PT/PTT
Avoid ASA, NSAIDS, Warfarin Nasal Oxygen	Transfuse Platelets Cryoprecipitate FFP		1. HCT > 65% Phlebotomy until Hct < 65% 2. Decreased Platelets Plt transfusion intraoperative 3. Increased PT/PTT FFP/Cryoprecipitate intraoperative
| FFP, fresh-frozen plasma | Hb, hemoglobin | Hct, hematocrit | | Plts, platelets | PT, prothrombin time | PTT, partial thromboplastin time |

 

In the iron-replete state, hyperviscosity symptoms may occur, typically when hematocrit levels are in excess of 65%. Dehydration secondary to excessive heat, illness, fever, diarrhea, or vomiting should be ruled out and managed appropriately with volume replacement. Avoidance of excessive perspiration combined with the used of an air conditioner, if possible, should be encouraged when appropriate. If dehydration is not a factor and the symptoms of hyperviscosity are moderate to severe in the setting of a hematocrit level greater than 65%, phlebotomy becomes the treatment of choice. Removal of 500 mL blood over 30 to 45 minutes followed by quantitative volume replacement with normal saline or dextran for patients with congestive heart failure usually can be achieved in an outpatient setting. Blood pressure is recorded before the phlebotomy in the supine and upright positions and is monitored every 15 minutes for the next 1 hour. Symptomatic relief should appear within 24 hours. The procedure can be repeated every 24 hours until symptomatic improvement occurs. This will typically by achieved with the removal of less than 2 L blood an sometimes with as little as 250 mL.

An increased hematocrit level, in and of itself, does not constitute an indication for phlebotomy. An asymptomatic patient with stable compensated erythrocytosis should not be phlebotomized, no matter how high the hematocrit level. Repeated phlebotomy under these circumstances with only lead to iron defieciency, the symptoms of thich can mimic those of normocytic hyperviscocity and lead to a state of decompensated erythrocytosis.

 

 

Adapted from:

Medical Management of Cyanotic Congenital Heart Disease in Adults
Judith Therrien, MD, FRCP(C), and Ariane J. Marelli, MD, FRCP(C)