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Parasitology Unit, Department of Microbiology and Molecular Genetics, The Kuvin Center for the Study of Infectious and Tropical Diseases, The Hebrew University, Hadassah Medical School, P.
This is an open access article distributed under the Creative Commons Attribution Licensewhich permits unrestricted use, distribution, and reproduction in any Soda für Thrombophlebitis, provided the original work is properly cited.
A written informed consent should be obtained from the patient before hirudotherapy is initiated. The patients should be treated each day of leech therapy with anti- Aeromonas antibiotics.
Leeches should be applied on the darker spots of the reattached body parts or flaps. Usually 1—10 leeches are used for each treatment, while at Soda für Thrombophlebitis beginning, the patient might need two or more Soda für Thrombophlebitis per day. Leech therapy is used until venous capillary return is established across the wound border by angiogenesis.
Usually the treatment with leeches lasts for 2—6 days. Signs of regional lymphadenitis, slight swelling, and pain of regional lymph nodes on the side of leech application and subfebrile temperature can occur.
Contraindications related to hirudotherapy include arterial insufficiency, hemophilia, hemorrhagic diathesis, hematological malignancies, anemia, hypotension, and sepsis.
Leech therapy is not recommended in pregnancy and lactation and in patients with an unstable medical status, history of allergy to leeches or severe allergic diathesis, Soda für Thrombophlebitis disposition to keloid scar formation, as well as in those using anticoagulants and immunosuppressants. Medicinal leeches have been used in the past 50 years for the salvage Soda für Thrombophlebitis tissue with venous congestion.
InDeganc and Zdravic [ 1 ] conducted the first treatment of congested flaps using leeches. Today, especially in the field of reconstructive microsurgery, medicinal leech therapy is enjoying a renaissance for review see also [ Soda für Thrombophlebitis3 ]. Leeches are generally used during the critical postoperative period when venous outflow cannot match the arterial inflow, which can lead to venous congestion, clinically identified by the von Thrombophlebitis purple appearance of the skin.
If this complication is not corrected, cell death may result and the flap or Soda für Thrombophlebitis may be lost. Therefore, medicinal leeches are used to salvage compromised microvascular free-tissue transfers, replanted digits, ears, lips, and nasal tips until angiogenesis gradually improves the physiological venous drainage [ 4 ].
In addition to using leech therapy in head and neck reconstruction, there are numerous studies showing the use of leech therapy for hematomas, penile and total scalp replantation, and pedicled skin flaps, as well as for the salvage of the entire lower limp [ 6 — 19 ]. Leech therapy is usually initiated after failure of more conventional treatment modalities such as warming, aspirin, rheomacrodex Soda für Thrombophlebitis. Venous obstruction causes microcirculatory thrombosis, platelet trapping, and stasis.
Thus, even after successful reanastomosis, secondary changes in the microcirculation can persist and prevent adequate outflow from being reestablished. Free flaps, pedicled flaps, and replanted tissues can survive arterial insufficiency for up to 13 hours, but venous congestion can cause necrosis visit web page three hours.
Medicinal leeches may be helpful in treating tissues with venous insufficiency by establishing temporary venous outflow, until graft neovascularization takes place [ 20 ]. In Julythe FDA Soda für Thrombophlebitis leeches as a medical device in the field of plastic and reconstructive surgery. A survey of all 62 plastic surgery units in the United Kingdom and the Republic of Ireland showed that the majority of these units uses leeches postoperatively [ 21 ].
The aim of these recommendations is to review the practical use of medicinal leeches in reconstructive plastic surgery by reporting our experience with leeches in cases of reimplanted digits and free-tissue transfers. Once venous congestion has been identified and the patient has agreed to undergo leech therapy, it is important that the patient is informed about the benefits and potential risks of the treatment. There is a general consensus that antibiotic prophylaxis for the Aeromonas bacteria, which are symbionts of leeches and which could lead to complications, should be initiated before leech therapy [ 2223 ].
Aeromonas species are sensitive to second- and third-generation cephalosporins, fluoroquinolones, sulfamethoxazole-trimethoprim, tetracycline, and aminoglycosides, while Aeromonas is resistant to penicillin, ampicillin, first-generation cephalosporins, and erythromycin [ 1624 — 27 ]. However, out of 21 isolates of Aeromonas species isolated from the water collected from the leech tanks, Soda für Thrombophlebitis All isolates were sulfamethoxazole-trimethoprim susceptible, which was also used as a prophylactic antibiotic regimen of choice for leech therapy [ 28 ].
A regular surveillance to detect resistant Aeromonas species in medical leeches, by controlling the water in which they are kept, was Soda für Thrombophlebitis. In the Iowa Head and Neck Protocol [ 30 ], levaquin is administered before the first leech is applied to the skin and continued until 24 hours after leech therapy is discontinued.
Use of narcotics and benzodiazepines should be minimized, because they could negatively influence leech activity, while the treated area should be photographed under the same light conditions using the same camera periodically to follow the read more of decongestion [ 29 ].
According to the literature, in most cases the medicinal leech Hirudo medicinalis was used. In some cases, similar results were also obtained with Hirudo verbana and Hirudo michaelseni [ 1731 ].
Using mitochondrial Blume Kastanien aus Krampfadern and nuclear microsatellites, Siddall et al. Leeches should be purchased from recognized leech producing companies, where they are kept in appropriate farms and fed artificially with animal blood. In addition, leeches purchased from recognized leech farms are sufficiently starved prior Soda für Thrombophlebitis being sold and some of the leech farms have been approved by regulatory agencies.
Leeches, which were collected from a natural environment, should not be used Soda für Thrombophlebitis hirudotherapy. Leeches can survive one year or more without a blood meal. Therefore, it is recommended to keep Soda für Thrombophlebitis large number of leeches in the laboratory by changing the water once or twice weekly. A larger stone should be added into the container, which would help leeches during the process of shedding their integument.
When click here leeches from one container to the other, the Soda für Thrombophlebitis water must be at the same temperature as the original. Approximately 8 leeches should be kept in 1 liter of water. Leeches should be handled gently by wearing nitrile or latex gloves, which would also prevent leeches from biting the health provider during maintenance of or treatment with leeches.
Before application, leeches are thoroughly rinsed Soda für Thrombophlebitis deionized water. The area to be exposed to leeches should be cleaned with sterile distilled water and ointments such as Doppler gel are removed.
In general leeches should be applied on the darker spots of the reattached body parts or flaps. In the case of reimplanted fingers, leeches could be also placed on the region of the removed nail.
For this purpose, the nozzle of the syringe is removed using a scissor or scalpel. The leech is placed in the barrel of the syringe and the open end of Soda für Thrombophlebitis syringe is placed on the area to be treated. When the leech Soda für Thrombophlebitis feeding, the syringe is removed gently Figure 1.
Leeches normally start feeding immediately, although in some cases the skin has to be punctured with a sterile needle so that oozing blood will stimulate the leeches to feed. Pricking the site to be treated could also demonstrate whether there is sufficient blood-flow in the area.
When the leech refuses to feed in a given place, the syringe is moved to the neighboring area, until an appropriate place is found as close as possible to the congested area.
During feeding drops of clear liquid can be seen oozing from the leech Figure 2 ; this is the superfluous water in blood, which the leeches remove to concentrate the red blood cells in their digestive tract.
During hirudotherapy the patient should Soda für Thrombophlebitis under permanent surveillance by a healthcare provider; leeches may seek other places to suck blood or after feeding may drop into Soda für Thrombophlebitis surrounding area. In cases of intraoral leeching, the path Soda für Thrombophlebitis the oropharynx should be blocked with gauze to prevent leech migration into the more distal aerodigestive tract, and the perioperative tracheotomy is left in position to protect the airway [ 29 ].
Specially shaped glass containers can be used for this purpose [ 33 ]. It could be assumed that they are only attached but not feeding and should be replaced with other leeches or they should be transferred to other parts of the treated area.
The use of active swimming and larger leeches could be of help. Depending on the severity and the size of the congestion, 1—10 leeches are used Soda für Thrombophlebitis each treatment, although some authors recommend higher numbers of leeches. The degree of venous congestion is estimated from the percentage of violaceous color of flap skin pedicle, testing capillary refill, and color of the blood oozing from the bite site or after having read more pierced with a needle.
At the beginning Soda für Thrombophlebitis the treatment, the patient might need two or more treatments per day. In the Iowa Head and Neck Protocol [ 30 ], leeches are applied every 2 hours. The number of treatments per day depends visit web page on the bleeding Soda für Thrombophlebitis previous bite sites.
In cases where the bleeding stops shortly after the leeches detach, or when leeches do not become fully engorged, a more aggressive treatment should be followed by using a larger number of leeches and more treatments per day. In fact, the decision regarding the duration of the leech treatment is empiric, based on subjective appreciation of the color of the skin, capillary refill, and the color of bleeding after pinprick [ 122934 — 36 ].
However, the wound may continue to ooze up to 24 hours after the leech Soda für Thrombophlebitis removed. However, the number of hematocrit checks depends on the number of leeches used, frequency of sessions, and total duration of therapy. In Israel, Mumcuoglu et al.
Of the 15 fingers, 10 fingers were saved Similar results were reported from countries such as the USA [ 1522 ], UK [ 17 ], Germany [ 39 ], and S. Africa [ 31 ]. The degree of Symptome von und sie platzen Soda für Thrombophlebitis can be estimated by describing the percentage of ruborous and violaceous color of Uzi mit Krampfadern der unteren Extremitäten flap skin pedicle, testing capillary refill, and observing color and amount of blood oozing from leech bite sites.
Serial photographs can help assess the intensity of venous congestion on a daily in frühen der Varizen Phase. The progress of treatment should be also documented. It should be kept in mind that venous obstruction causes microcirculatory thrombosis, platelet trapping, and stasis.
Thus, Soda für Thrombophlebitis after successful reanastomosis by leeches, secondary changes in the microcirculation can persist and prevent adequate outflow from being reestablished.
Modern leech therapy is generally recognized as a relatively safe and well-tolerated treatment modality. A patient who refuses to sign the consent form, refuses prophylactic treatment with antibiotics, or refuses blood transfusion click at this page not be treated with leeches.
Although the bite of a leech is felt as a slight pain on the intact skin, this is not relevant in the case of recently reattached digits and flaps, where the skin is anesthetic. Slight localized itching of the Y-shaped bite site Figure 4 persisting for several hours and up to 3 days is the most common In severe cases of generalized itching, topical corticosteroids and oral antihistamines should be prescribed.
Signs of regional lymphadenitis, slight swelling, and pain of regional lymph nodes on the side of leech application and subfebrile temperature can occur in 6. Apparently, such adverse reactions never appear when leeches are applied on oral, nasal, or vaginal mucosa. In very rare cases, allergic skin reactions have been observed. When leeches are applied to the esthetically important areas with thin skin and thin layers of subcutaneous tissue scarring after a leech bite could be a cosmetic problem.
In some cases, application to a nearby mucosal surface could avoid these complications [ 33 ]. Leech-borne Serratia marcescens infections were also reported [ 24 ]. Accordingly, prophylactic treatment with antibiotics is necessary. Aeromonas infections can occur acutely within 24 hours or in a delayed fashion up to 26 days after the beginning of leech Novosibirsk Behandlung Thrombophlebitis. Clinical manifestations of Aeromonas infection vary from a minor wound infection to extensive tissue loss.
It is important to stress that leech related Aeromonas infections more frequently develop in very sick and immunosuppressed patients. When applied on intact skin, for example, in patients treated for osteoarthritis, local pain, arterial hypertension, and different forms of spondylosis and dorsopathies, Aeromonas infections are extremely rare.
The excess bleeding after leeching can be of concern and transfusions may be needed, Soda für Thrombophlebitis in patients with a tendency to hemorrhage, who suffer from anemia, or for those taking anticoagulants or platelet-inhibiting drugs. Usually, 3—6 units of packet blood cells are used to compensate for blood loss. In very rare cases, thrombotic microangiopathy and renal Soda für Thrombophlebitis have been reported when leeches were applied in patients with Soda für Thrombophlebitis insufficiency [ Soda für Thrombophlebitis ].
Isolated reports describing the appearance of syncopal status or orthostatic hypotension mainly in older persons with initial sympathicotonia at the start of or during leech therapy, have been Soda für Thrombophlebitis. According to Michalsen et al. It is highly recommended that patients drink plenty of fluids during hirudotherapy. In order to prevent those systemic side effects, hirudotherapy should be performed in a calm atmosphere, under Soda für Thrombophlebitis blood pressure monitoring, and with Soda für Thrombophlebitis patient lying down.
In fact many patients treated with leeches and who had successful treatment changed their attitude towards hirudotherapy in Soda für Thrombophlebitis positive way. Nevertheless, it Soda für Thrombophlebitis be necessary to prepare the patients psychologically Soda für Thrombophlebitis the application of Soda für Thrombophlebitis [ 4142 ]. Contraindications related to hirudotherapy include arterial insufficiency, hemophilia, hemorrhagic Soda für Thrombophlebitis, hematological malignancies, expressed and firm anemia, expressed and firm hypotension, sepsis, Soda für Thrombophlebitis, decompensated forms of hepatobiliary diseases, any form of cachexia, and individual intolerance to leeches.
Leech therapy is also not recommended in pregnancy and source, in patients with an unstable medical status, history of allergy to leeches or severe allergic diathesis, Soda für Thrombophlebitis to keloid scar formation, arterial insufficiency, and in those using anticoagulants, immunosuppressants, and some vasoactive drugs such as Ginkgo biloba products [ 33 ]. Hirudotherapy depends on the following main properties of medicinal leeches: the blood-letting action during active suction of blood, passive oozing of the wound, and injection of biologically active substances with the saliva into the host.
The saliva of H. One of the most important ingredients is hirudin, which is the principal anticoagulant responsible for enhanced bleeding and prevention of coagulation. In addition to hirudin, leeches secrete two inhibitors of Factor Xa responsible for the conversion of prothrombin to thrombin [ 45 ]. Furthermore, leech saliva is an effective Soda für Thrombophlebitis aggregation inhibitor due to the presence of active ingredients such as calin, apyrase, platelet activating factor PAF- antagonist, collagenase, and prostaglandin.
The medical benefit to the patient is Soda für Thrombophlebitis sustained local bleeding that can last several hours after the end of each leech session. Medicinal leeches also secrete hirustasin, which selectively inhibits tissue kallikreins that are largely responsible for the maintenance of a normal level of blood pressure. Hirustasin can also play a role in the intrinsic coagulation process [ 49 ].
The anti-inflammatory and analgesic properties of leeches are subjects of modern hirudobiochemistry and hirudopharmacology and in many aspects are associated with the blockage of amidolytic and kininogenase activities of plasma kallikrein, resulting in prevention Soda für Thrombophlebitis pain or pain relief during leech sessions [ 50 ].
Leeches may also secrete a vasodilative, histamine-like substance, which increases the inflow of blood after a leech bite and reduces local swelling [ 45 ]. Tissue permeability, restored go here the help of hyaluronidase, promotes the elimination of tissue- and circulatory-hypoxia as well as local swelling [ 51 ].
The persistent bleeding largely potentiates tissue decongestion and leads to loss of blood, relief of capillary net, decrease in venous congestion, decompression of the nerve trunks and endings, increase in lymph flow, positive changes of local hemodynamics, amelioration of hemorheology, increase of oxygen supply, improvement of tissue metabolism, and elimination of tissue ischemia [ 33 ].
In summary, hirudotherapy is a safe, easy click the following article use, beneficial, and cost-effective treatment modality to save reattached body parts and flaps in reconstructive plastic surgery. The early recognition of flap failure and initiation of leech therapy is of paramount importance. Prophylactic treatment with antibiotics and continuous monitoring of blood parameters are necessary.
The author declares that there is no conflict of interests regarding the publication of this paper. Evidence-Based Complementary and Alternative Medicine. Citations to this Article.
How to Cite this Article. Abstract A written informed consent should be obtained from the patient before hirudotherapy Soda für Thrombophlebitis initiated. Introduction Medicinal leeches have been used in the past 50 years for the salvage of tissue with venous congestion. Conditions for Treatment with Leeches Once venous congestion has been identified and the patient has agreed to undergo leech therapy, it is important that the patient is informed about the benefits and potential risks of the treatment.
The Medicinal Leech According to the literature, in most cases the medicinal leech Hirudo medicinalis was used. Application of Leeches to the Skin Before application, leeches are thoroughly rinsed with deionized water. Figure 1: Application of a leech to the area to be treated using a syringe.
Figure 2: Feeding leech: transparent liquid can be seen oozing from the body of the leech. Figure 3: Treatment of a skin flap of the face, after removal of the skin with scars and coverage of the area with the enlarged, adjacent skin. Dobos, Medicinal Leech TherapyGeorg Thieme, New York, NY, USA, article source View at Google Scholar M.
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