Leeches have been used for medicinal purposes for 2,500 years. Their contemporary use in plastic surgery, first described in 1836, is for the relief of soft tissue venous congestion, most commonly in compromised flaps and in avulsed or replanted appendages such as the ear and finger. Leeches have proven especially useful in microsurgery, in which venous anastamoses may prove challenging. The success rate of salvaging tissue with medicinal leech therapy has been reported to be up to 70-80%. In 2004, the U.S. Food and Drug Administration approved the commercial marketing of leeches for medicinal purposes.
Medicinal leeches, typically Hirudo medicinalis, are distinctive in their ability to effect prolonged venous bleeding, simply because they inject salivary substances that have anticoagulant, antiplatelet and vasodilatory effects. These components trigger bleeding for up to 24 hours, lengthy after the leech has been removed. Leeches also release a local anesthetic, rendering bites painless.
The indication for the use of leeches is venous congestion. This diagnosis can be made by observing the following signs: cyanosis, edema and brisk capillary refill. Pricking the affected area having a needle outcomes in dark bleeding. Intraoperative problems, like difficulty with a venous anastomosis or undue pedicle tension, also suggest the diagnosis. When flaps are congested, other mechanical means to enhance venous outflow should be considered first, including removing tight sutures, decompressing tunneled pedicles, and evacuating hematomas.
While the initial leech bite causes about 5-15 ml of blood loss, each wound can ooze an extra 50-150 ml of blood over a period of up to 24 hours. As such, the number and timing of leeches to be applied should be tailored to the area involved. Venous ingrowth may be anticipated in 3-5 days. Treatment should be continued until signs of venous congestion subside. This might take up to 10 days.
Leeches are commercially obtainable from several sources. After receipt, leeches may be stored in the pharmacy or on the patient floor. They must be refrigerated and kept in a feeding medium (either dissolved in distilled water or a gel) that arrives with them. A general approach is as follows:
1. Clean the skin thoroughly with soap and water. It's particularly essential to remove old antiseptic or other noisome substances, as they might affect the leech's appetite.
2. Cut a 1 cm hole in the middle of a saline-moistened gauze sponge. Location this sponge so that the hole overlies the area to which the leech would be to be applied.
3. Location the leech on the gauze pad such that its head (the end that tends to move the most) is against the skin. It may be helpful to location the leech in the barrel of a 5 ml syringe (after removing the plunger) and inverting the syringe against the skin so that the leech may be specifically applied.
4. Leeches will usually attach instantly. If not, prick the skin with a needle before reapplying the leech.
5. Leeches will typically remain in the same place until they're completely distended, at which point they'll fall off. This generally takes 30-45 minutes. Instruct the patient's nurse to check on the patient frequently so that leeches aren't lost after detachment.
6.Wounds may be encouraged to bleed after detachment by occasionally scraping the eschar off.
7. Used leeches can be discarded by anesthetizing and then euthanizing them in 8% and 70% alcohol, respectively. They should be considered biohazardous and disposed of as such.
If a number of leeches are used concurrently, it may be essential to check the patient's hemoglobin/hematocrit at regular intervals. All patients should be started on an oral antibiotic while on leech therapy. Suggested antibiotics include a fluoroquinolone or amoxicillin/clavulanic acid. Patients with HIV or taking immunosuppressive medications ought to not undergo leech therapy because of the risk of bacterial sepsis.
Leeches should be used as a treatment of last resort when all other means of venous outflow establishment are exhausted. It is imperative to relieve a mechanical or iatrogenic trigger of venous compromise. It's critical to rule out arterial insufficiency as the trigger of flap necrosis or pallor, since leeches will not work in this scenario.
Flaps demonstrate considerably decreased survival after 3 hours if venous congestion is not relieved. As opposed to arterial ischemia, venous stasis tends to cause irreversible damage. Since leeches must be flown in, it's wise to anticipate their need as early as possible. We have ordered them intraoperatively in some cases. Although leeches may be reused on the exact same patient, they tend not to work as well. Utilized leeches ought to not be stored with unused ones to stop cross-contamination. Utilized leeches ought to by no means be applied to another patient.
The importance of an suitable bedside manner in ensuring acceptance of and compliance with this regimen can't be understated. Most patients are willing to accept treatment when it is explained in a thorough and confident manner. It's also critical to include nursing and ancillary staff in the discussion of leeches, as numerous will not have seen them used before. We have discovered that by observing the first application of a leech, most nurses are willing to apply subsequent leeches without supervision.
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