Transcription

1 Maria Georgiades PGY 1 June 12, 2009

2 Overview Case presentation Historical review Indications for leech therapy Mechanism Proper handling of leeches Complications Future uses

3 H.G. 47 year old female with history of recurrent left breast cancer who was admitted on 5/29 and underwent a MRM and TRAM flap reconstruction. Patient s flap was monitored for viability daily and underwent an unremarkable hospital course. Patient was discharged on POD #5. On POD# 7 the patient went for a follow up visit and was admitted into the hospital with venous congestion of the left breast TRAM flap.

4 H.G. 2 PMH: Left breast cancer s/p lumpectomy and sentinel LN biopsy PSH: TAH/BSO Allergies: NKDA Md Med: none SH: negative for use of cigarette, occassional alcohol, no drug use

5 HG Physical Exam: Breast: Left: purplish discoloration of flap, tender to palpation, firm to palpation Right breast: no change in size or shape, no nipple discharge, g, no masses palpatedp Rest of exam was WNL Labs: CBC: 12/7.4/22/504 BMP: 138/4/102/24/11/0.8/113

6 HG HD1 patient begun on leech therapy q1 2 hrs; patient begun on zosyn for prophylaxis HD2 H/H : 7.6/20 and patient was transfused 2 units of PRBC HD3 7: continued the leech application and daily CBC

7 HD #2

8 Historical Review First recorded in therapeutic practice in 2 nd century BC Practice peaked in 18 th and first half of 19 th century in which h the leech became and endangered d species in Europe 1960 Slovenian surgeons used leeches for tissue flap surgery

9 Indications Indications for ancient leeching and mental disorders Whooping cough Gout Tumors Headache Obesity Pneumonia Pleurisy Liver disease Gonorrheal Orchitis Acute gastritis Moderna leeching Indications Digital replantation Auricular replantation Total scalp replantation Penile replantation Congested nipples Skin grafts Non traditional use of leeches Sublingual hematomas Purpura fulminans Ear infections Lingual swelling Periorbital hematoma

10 Hirudo Medicinalis Freshwater hermaphrodite black or brown Member of Phylum annelida About 10 cm in length Cephalic sucker Mouth of a leech has 3 jaws Each jaw has 100 tiny teeth Use caudal suction device for stability to attach to surface

11 Mechanism Initial painless bite Saliva contains a mild anesthetic Attachment period of minutes Sucks 5 15mL of blood Post attachment period Site continues to bleed for several hours Stored at cool temp Calin inhibit plt adhesion and activation Final stage: Hirudin: a protein anticoagulant that inhibits thrombin Histamine like substances Induce vasodilation and increase blood flow to the area Hyaluronidase, collagenase and proteinase inhibitors Destabilase inhibits ADP platelet aggregation

12 Patient assessment Venous congestion Skin has purple appearance and engorged, taut a Warm to touch Capillary refill is brisk and instantaneous (<1s) Leech therapy is contraindicated t d in arterial insufficiency

13 Attaching the leech Wash the area with soap and water and rinse with distilled nonchlorinated water Gently grasp the leech Using a syrine and removing the plunger, place leech in barrel and direct head to the site Usually attach in a U shape May encourage attachment with drop of glucose or may prick ik skin with sterile needle Prevent leech migration using gauge Do not force leech off

14 Placement of leech

15 Satiated leeches Detach spontaneously Feeding times range: minutes Greater benefit of leeches: blood loss after detachment because of slow oozing at site of bite Leech should be destroyed d by placing it in 70% alcohol l solution

16 Complications Excessive bleeding Serial CBCs Controlled by direct pressure or topical thrombin May necessitate blood transfusion Allergic Reactions Infection Most serious complication (7 20%) Aeromonas hydrophila GN bacillus that enables breakdown of ingested blood 2 11 days after therapy Result in abscess and cellulitis l Prophylactic antibiotics given

17 HD 7

18 Future Uses Recombinant hirudins ( r hirudins) as alternative anticoagulant to heparin Can be used for effective anticoagulation i in patients with antithrombin III deficiency May also extend to the prevention and treatment of venous thrombosis, coronary thrombosis after angioplasty during hemodialysis or cardiopulmonary bypass

19 Resources Zhao X, Higgins KM, Enepekides D, Farwell G. Medicinal leech therapy for venous congested flaps: case series and review of the literature. J Otolaryngol Head Neck Surg Apr;38(2):E61 4 Abdelgabar b AM, Bhowmick Bk. The return of the leech. Int J Clin Pract 2003; 57 (2): Yantis MA, O'Toole KN, Ring P. Leech Therapy. Am J Nurs Apr;109(4):36 42;. Review.

20 THANK YOU