Blood-letting was once one of the main medical treatments offered to patients before the advent of modern medicine, but did you know it is still a possible therapy that can be used in the ED today? According to a study by Eiser et al in 1997, and advocated by Dr. Reuben Strayer on the EM:RAP podcast, phlebotomy can be used as a last-ditch effort for dialysis patients with acute crashing pulmonary edema.
If your nitro drip and amped-up ventilator settings aren’t cutting it and the renal fellow says your patient’s dialysis won’t be possible for a few hours, removing 200-300 cc’s of blood can be a bridge to definitive treatment. This doesn’t mean that the mainstays of treatment should be ignored (aggressive use of nitro and bipap/intubation), but if your patient continues to desaturate despite your best efforts, this may be a last-ditch tool you can keep in your back pocket for a rainy day.
Eiser, AR et al. Phlebotomy for pulmonary edema in dialysis patients. Clin Nephrol. 1997 Jan;47(1):47-9. PMID: 9021241
Strayer, R. (2016, October) Strayerisms: Acute Pulmonary Edema. https://www.emrap.org/episode/sayhellotobrue/strayerisms