Leech Mania

1. Leech Mania Anne Redick, RN, CNL 10 East Surgical Oncology

3. Objectives Hx Pt populations Guidelines Prevent. Complications Post. Pt outcomes

4. Medicinal Leech Therapy

5. History First used 2500 years ago The bite of a leech produces An anticoagulant A local vasodilator This mimics venous circulation in compromised tissue Bleeding can continue up to 48 hours after leech detachment

6. Patient Populations Microvascular anastomoses (Flaps) Head & Neck Cancer Plastic Surgery Tissue reattachment Digits Ring avulsion injury Patients may catch their wedding band or other finger ring on moving machinery or on a protrusion from a surface as they jump or move away from it Patients may catch their wedding band or other finger ring on moving machinery or on a protrusion from a surface as they jump or move away from it

7. Guidelines Provides standardized guidelines for prescribing, dispensing and applying medicinal leeches Guidelines divided into three sections for clarity: Pre-procedure, procedure, post-procedure

8. Pre-Procedure Physician obtains informed consent Writes order for sterile medicinal leeches Specifies number of leeches, and area to be treated Orders baseline hemoglobin and hematocrit Orders supplies to be kept at bedside Suggested supplies listed in guidelines Nurse Provide patient teaching Collect supplies & begin procedure

9. Procedure Nursing cleanses treatment area Applies leech to area specified by physician Monitors the leech frequently to prevent migration to non-treatment area Allows the leech to remain in place until fully distended (10-15 minutes) Allows the leech to detach naturally or apply salt to the head

10. Post-procedure Place used leech in cup containing 70% alcohol and screw on cap Place used leech in red bag and dispose of according to MUHA infectious waste policy Encourage bite to bleed by removing locally forming clots

11. Appendices Appendices from Leeches U.S.A. LTD Http://www.leachesusa.com Fact sheet on leeches Procedure for attaching leeches Equipment needed to apply leeches Maintenance of leeches Disposal of leeches General patient care and post bite care of wounds

12. Preventing Complications Observe Leech during treatment for migration Check Hemotocrit/Hemagolbin pre-procedure and at least every 48 hours Prophylactic antibiotics (Keflex PO) Assess Flap Doppler Color Temperature Capillary Refill Turgor

13. Positive Outcomes STATS ? ENT & Plasics state satisfaction with results Cost Savings $4-$6 per Leech vs. Surgical Revision Patient Satisfaction Decrease LOS / Prevent Readmission for Surgery Emotional Impact Dr O (plastics) stated that he hasn�t lost a flap but has had to do partial revisions, he also stated that the tissue was already is poor condition when the leeches were applied so in his opinion partial success was good success. Dr Hornig (ENT) stated that out of 4 cases ( one pec flap, two skin flaps, one free flap) he hasn�t lost a complete flap although two had partial flap loss. Dr O (plastics) stated that he hasn�t lost a flap but has had to do partial revisions, he also stated that the tissue was already is poor condition when the leeches were applied so in his opinion partial success was good success. Dr Hornig (ENT) stated that out of 4 cases ( one pec flap, two skin flaps, one free flap) he hasn�t lost a complete flap although two had partial flap loss.

14. Success Stories Mr. A is a 23 y.o . White male with SCCA of the Anus s/p APR with flap closure by plastics. Several days post-op Nursing staff noted that the flap was dusky & was unable to obtain a venous doppler signal. Leech therapy was initiated by plastic surgery team 3-4 leeches were applied every 2 hours to rectal flap. Treatment continued for 2 weeks with decreasing placement intervals Pain Nurse & Psychiatric Nurse Liaison Consult were made due to pt anxiety and poor pain tolerance Patient discharged with viable flap However, Mr. A. was readmitted 10 days after discharge with complications due to poor hygiene and noncompliance. The flap developed a foul odor and necrotic edges. Cultures obtained were positive for pseudomonas. Wound Vac was placed after wound debriedment.

15. Success Stories cont. Mrs. L a 67 y.o.white female with SCCA of the Lip underwent multiple resections and reconstructions beginning in 1996. Her most resent hospitalization was for lower lip soft tissue defect s/p recurrent cancer resection. After transfer to the floor her lip flap became dusky and was concerning for venous congestion. She received a single leech to her lip every 2 hours for several days. The flap remained pink and soft with good viability after the discontinuance of leech therapy. She continues to seek further reconstruction for appearance and function

16. Success Stories cont. Other patients Head & Neck Cancer Ear Other facial and neck flaps Plastic Breast Rectal Shoulder Abdomen

17. http://video.google.com/videoplay?docid=-3633022247833962305&q=leech+treatment&hl=en