Ultrasound Guided Small-bore Peripheral Catheter Placement for Large Volume Therapeutic Phlebotomy

Abstract

Introduction: The practice of therapeutic phlebotomy is used today to treat conditions such as hemochromatosis, polycythemia vera, and transfusion-related iron overload (TRIO) in survivors of childhood cancer. Iron overload is toxic and a potential long-term complication for cancer survivors who received multiple transfusions during therapy. Venipuncture is the most common source of pain and anxiety in the pediatric patient population and is challenging in oncology patients due to their extensive history of phlebotomy and IV access. Ultrasound-guided small bore peripheral vascular access has proven to be a reliable and sustainable method for performing large volume phlebotomy.

Case Report: A 12-year-old female with a past medical history of B-cell acute lymphoblastic leukemia was receiving biweekly iron chelating therapy. The patient had a surgically implanted port for infusions and phlebotomy but developed fungemia and the port was removed. The family did not want the port replaced because of the severity of illness the patient experienced from sepsis. The outpatient infusion center was successful at establishing vascular access only after five attempts in the past two visits for therapeutic phlebotomy. The patient was referred to the Vascular Access Service for placement of an ultrasound-guided peripheral IV (PIV) catheter. Using ultrasound guidance with a short axis approach a 22-gauge 1.88-inch closed system (extension tubing incorporated) PIV was placed to the brachial vein and therapeutic phlebotomy was performed using 10-mL syringes. The patient continued to receive ultrasound-guided PIVs for the duration of her iron chelating therapy.

Conclusion: The placement of ultrasound-guided small-bore PIVs to the brachial vein for therapeutic phlebotomy and infusion therapy in the difficult access patient can postpone or avoid placement of a tunneled or surgically implantable venous access device in children with hematologic disease or cancer.