What is the protocol for therapeutic phlebotomy in a patient with elevated hemoglobin (hyperhemoglobinemia)?

Protocol for Therapeutic Phlebotomy for Elevated Hemoglobin Over 20 g/dL

Indications for Therapeutic Phlebotomy

Therapeutic phlebotomy is indicated for patients with hemoglobin greater than 20 g/dL and hematocrit greater than 65%, associated with headache, increasing fatigue, or other symptoms of hyperviscosity in the absence of dehydration or anemia. 1

Additional indications include:

• Before noncardiac surgery when hematocrit is >65% 1
• Symptomatic hyperviscosity (headache, lethargy, dizziness, poor concentration) 1

Pre-Phlebotomy Assessment

Before initiating therapeutic phlebotomy:

• Confirm hemoglobin >20 g/dL and hematocrit >65%
• Rule out dehydration (which can falsely elevate hemoglobin)
• Check for symptoms of hyperviscosity
• Assess iron status (serum ferritin, transferrin saturation)
• Evaluate hydration status
• Assess baseline vital signs

Phlebotomy Protocol

1. Volume and Frequency:

   • Remove 1 unit of blood (450-500 mL) per session 2
   • Always replace with equal volume of dextrose or saline 1
   • Initial frequency: Weekly or biweekly sessions 2

2. Monitoring During Procedure:

   • Continuous vital sign monitoring
   • Observe for signs of hemodynamic instability
   • Monitor for symptoms of hypovolemia

3. Laboratory Monitoring:

   • Check hemoglobin before each phlebotomy session 2
   • Reduce frequency if hemoglobin <12 g/dL 2
   • Pause treatment temporarily if hemoglobin <11 g/dL 2
   • Monitor serum ferritin levels regularly

4. Target Parameters:

   • Continue phlebotomy until hemoglobin <20 g/dL and hematocrit <65%
   • Aim for resolution of hyperviscosity symptoms
   • Avoid iron deficiency (maintain serum ferritin >50 μg/L) 2

Post-Procedure Care

1. Immediate Care:

   • Monitor vital signs for 30-60 minutes post-procedure
   • Ensure adequate oral hydration
   • Observe for signs of hypovolemia or vasovagal reactions
   • Provide written instructions about potential delayed reactions

2. Hydration:

   • Encourage increased fluid intake before and after procedure
   • Maintain good hydration between phlebotomy sessions
   • Avoid dehydrating activities for 24 hours post-phlebotomy

3. Activity Restrictions:

   • Avoid strenuous physical activity for 24 hours
   • Avoid hot environments (saunas, hot tubs) on day of procedure
   • No alcohol consumption for 24 hours post-procedure

Follow-Up Guidelines

1. Short-term Follow-up:

   • Reassess symptoms within 1-2 weeks after initial phlebotomy
   • Check hemoglobin and hematocrit levels before next session
   • Evaluate need for continued phlebotomy based on clinical response and laboratory values

2. Long-term Monitoring:

   • Once target hemoglobin/hematocrit achieved, establish maintenance schedule
   • Monitor hemoglobin/hematocrit every 3-6 months
   • Check serum ferritin and transferrin saturation every 6 months 2
   • Adjust frequency based on rate of hemoglobin/hematocrit rise

3. Warning Signs Requiring Immediate Attention:

   • Instruct patients to seek medical attention for:
     • Unusual bleeding or bruising
     • Severe headache or dizziness
     • Extreme fatigue
     • Symptoms of iron deficiency (glossitis, angular cheilitis)

Important Cautions

1. Avoid Repeated Routine Phlebotomies:

   • Repeated routine phlebotomies are not recommended due to risk of iron depletion, decreased oxygen-carrying capacity, and stroke 1

2. Iron Monitoring:

   • Monitor for iron deficiency, which can lead to production of iron-deficient red blood cells with reduced oxygen-carrying capacity and deformability 1
   • Iron deficiency increases risk of stroke in cyanotic patients 1

3. Special Considerations:

   • For patients with cyanotic congenital heart disease, always replace blood volume with dextrose or saline 1
   • Be cautious with oral iron supplementation if needed, as it can cause rapid increase in red cell mass 1
   • Ensure patients are well-hydrated before procedures involving contrast media 1

4. Contraindications:

   • Anemia
   • Hypovolemia
   • Hemodynamic instability
   • Active infection

By following this protocol, therapeutic phlebotomy can effectively manage hyperviscosity symptoms in patients with elevated hemoglobin while minimizing risks of complications such as iron deficiency and stroke.