Procedure for Leech Therapy

Prior to beginning the procedure, check to make sure there is an order for leech therapy. Also check for prophylactic antibiotic orders. The condition of the tissue flap should be assessed for arterial flow, usually with a doppler probe. Patient vitals should be recorded prior to treatment. Patients who are anxious about the procedure may benefit from anti-anxiety medications. The order for such medication should be obtained prior to treatment so that the medication can be administered in time to affect relaxation. If anxiolytics are ordered, a minimum dose should be used to avoid depressing leech activity.Likewise, leech activity may be reduced by residual anesthetic if treatment is started immediately post-op. Gather supplies

Leeches in non-chlorinated water Disposal container with 70% alcohol solution (Label: contents, biohazard & patient name) Waterproof pads, towels Doppler & gel Bottle sterile water - not saline Sterile heparinized saline solution Sterile swabs Sterile 20 gauge needle Gauze 4x4s Scissors, Forceps (non-toothed) Exam gloves Basin, soap & water as ordered (strong odors, tastes and saline will offend the leech)

Procedure for application of leeches Usually, 1 or 2 leeches are sufficient to treat a partially degloved or replanted finger, whereas a large flap may require 6 or more. Leech treatments often continue for 5 days or more. Leeches attach more readily to areas where blood is oozing, so if the skin is intact, sometimes pricking the skin with a sterile needle (20 gauge) will encourage the leech to latch on. As with all treatments involving blood, strict adherence to universal precautions must be maintained.

The following is a typical procedure for leech application; steps may vary depending on recipient site and facility protocol:
Step Illustration Verify orders: 1 "5 rights" Anticipate IV antibiotics o Aeromonas hydrophila colonize leech gut o cefotaxime or ciprofloxacin Anticipate IV heparin (anticoagulant) Anticipate IV Dextran o osmotically active and decreases viscosity o inhibits RBC & platelet aggregation Action

Explain procedure to patient Warn against caffeine & nicotine

(vasoconstrictors)

Check vital signs Promote vasodilation o Maintain body temp as ordered (Bair Hugger) o Maintain room temp as ordered (78F)

Adjust lighting Arrange supplies Don gloves Position patient

Assess flap o Color, temp, bleeding, infection, sloughing, etc. Doppler arterial pulse o Document character of pulse

Universal precautions! Cleanse flap with mild soap and water Remove gel Rinse with sterile water

Cut hole 1cm in 4X4 sponge (leech "corral") Moisten 4X4 with sterile water Place 4X4 over site Gently pick up leech with forceps Do not squeeze; leech may regurgitate

Lay leech on wound and guide head to site The mouth will become round like a suction cup when attached, the neck slightly arches, it will start to swell and can't be moved. Alternate method: o Remove the plunger from a 5 cc plastic syringe and place the leech in the barrel of the syringe. Invert the barrel, placing the open end on the wound site, where you want the leech to attach. Once feeding commences, remove the syringe.

Record the number of leeches placed; they can detach and migrate. Stay until treatment is completed (per protocol), usually 10-30 minutes. Record length of treatment. Leech will swell, up to 5 x in size, and eventually fall off. Patient may lose up to 15 cc of blood per leech, per session, but wound may continue to ooze blood; up to 50 to 150 mls in some cases.

10

Account for and remove all detached leeches with forceps. Place them in container of 70% alcohol solution. NEVER pull the leech off. This could damage the tissue or cause the leech to regurgitate bacteria from the gut, contaminating the wound. Dispose of used leech container following procedures for contaminated biological waste products. Never re-use a leech on another patient. Neverreturn used leeches to the pharmacy

11

Hgb and Hct as ordered. Transfusion of packed RBCs is often required.

12

Assess for bleeding every 1-2 hours to make sure that the site of the leech attachment continues to ooze blood .Gently dislodge clots at the bite with heparinized saline soaked swab, as ordered.

Additional Considerations: Leech application to the head, neck or perineum may require additional vigilance and reassurance. Intra-oral application of leeches may require a throat pack (moist 4x4) and an alternate airway: tracheostomy or naso/endotracheal tube. Serial photo documentation of flap condition throughout leech therapy may be appropriate. If so, obtain specific consent.

Instant feedback:
Record the number of leeches placed and the number removed. True False

Care and storage of leeches Because leeches may be used as needed, they are often kept in the patient's room. They are usually stored in special solution (0.5g

Hirudosalt in 1 liter of distilled water). Water must not be chlorinated. The storage container should be kept in a secured, cool (<68 degrees), dark place with vents open to provide ventilation. Vent should be covered with gauze that is secured to prevent leeches from escaping as they can squeeze through very small spaces. Leech solution should be changed every other day. Leeches should not be overcrowded - no more than 50 in a 2-gallon container. Leech therapy documentation Thorough documentation is important so that the progress of the treatment can be properly evaluated. Documentation should include the following:

Orders & consent Daily HCT/Hgb Patient assessment: vital signs, orientation, pain, sensation, etc. Appearance of treatment area: color, temperature, sloughing, exudate, etc. Presence of Doppler pulse and changes Area treated, number used and accounted for, length of treatment Presence of oozing Other medications or treatments as ordered