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Leeches in PICU? (Critical Thinking In Critical Care).

This is a Critical Care Critical Thinking Problem (CCCTP) designed to test your problem solving and analysis abilities.

Instructions: Read the CCCTP below. Then outline how you would assess and expect this patient to be managed. Finally compare your rationale and decision to that provided in the shaded area.

We invite your contributions to this section of the journal. An honorarium of $50 will be paid to the author of a published CCCTP.

Please submit material to: Beth Suddaby; Inova Fairfax Hospital for Children; 3300 Gallows Rd.; Falls Church, VA 22042 or e-mail at elizabeth.suddaby@inova.com for author guidelines.

Tanya is a 3-year-old female admitted to the emergency room following the traumatic amputation of the index and middle fingers of her right hand in an all-terrain-vehicle (ATV) accident. According to report, she was riding with a family member when the ATV rolled over. As she fell off, her right hand caught the vehicle's chain, severing her first two fingers. Remarkably, this was Tanya's only injury. Until this time, Tanya was healthy with no significant past medical or surgical history. Accompanied by both parents, she was taken immediately to the operating room (OR) for replantation of her right middle finger. Her index finger was too damaged for replantation. Because of the dangers of severe swelling and blood engorgement after surgery, Tanya was initially taken to the pediatric intensive care unit (PICU) for intensive monitoring.

Assessment Findings

Vital Signs: HR 140, RR 20, BP 117/64, Temp 37[degrees]C ax., Weight 14 kg, Height 91 cm.

Neuro: Alert, irritable, and frightened of procedures and staff but comforted by the presence of her parents and her favorite brown bear.

Respiratory: Breath sounds equal and clear, oxygen saturation 100% on room air.

Cardiovascular. Sinus tachycardia; peripheral pulses 3+; skin--warm, dry, pale pink with good capillary refill (1-2 seconds); unable to assess right upper extremity pulses due to dressing.

Gastrointestinal: Abdomen soft, nondistended with active bowel sounds; tolerating small amounts of clear liquids; no stool.

Genitourinary: Voids spontaneously, using toilet (in process of potty training) but occasional incontinence.

Musculoskeletal: Moves all extremities, including right arm at shoulder.

Skin: Right upper extremity elevated, amputation at the proximal phalanx of the right index finger; hand dressed in layers of gauze and ace wrap; replanted middle finger oozing bloody drainage with increased swelling.

Initial Management Plan

The postoperative admission orders for Tanya included antibiotics, pain medications, and an antiplatelet agent to improve blood flow in Tanya's replanted middle finger. She was started on IV ceftriaxone, po or pr acetaminophen, IV fentanyl for pain, and a baby aspirin 81 mg every day po. A peripheral IV in the left antecubital infused D5 1/4NS at 50 cc/hr. Because of continuing concern about the development of edema leading to occlusion of the replanted finger's newly re-established arterial blood flow, the hand surgeon ordered a unique therapy. What do you expect that to be?

Continuing Management Plan

Leech therapy was initiated within 1-hour postsurgery. The therapy included leech applications and heparin scrubs. Our institution keeps leeches in the plastic surgery research lab. They may also be ordered directly from breeders such as Leeches U.S.A., Ltd.

On postoperative day 1, nursing assessed Tanya's replanted finger for color, capillary refill, and continual blood oozing every 1 to 2 hours. Leeches were applied as necessary to decrease venous congestion. A dusky, bluish color and brisker than normal capillary refill are classic signs of insufficient venous outflow and indications for leech therapy (Utley, Koch, & Goode, 1998). The continuous bleeding initiated by the leech bite relieves venous congestion. Therefore, it is important to reapply the leeches if bleeding stops (see Table 1). Other care included maintaining IV access, administering prophylactic IV antibiotics and oral aspirin, monitoring daily hemoglobin and hematocrit levels, administering packed red blood cells (PRBCs) when necessary, and medicating for pain. Once this plan was initiated and the finger was determined viable, Tanya was transferred to the general medical-surgical pediatric unit.

Not surprisingly, the nurses had feelings of apprehension and revulsion regarding the handling of leeches, which resulted in reluctance to accept Tanya as part of their patient assignment. Their lack of experience was complicated by not having an established protocol for leech therapy. The nurses were aware that their management of the leech therapy would be the critical factor in assuring that the re-attached portion of Tanya's digit would successfully "take," preserving both form and function (Golden, Quinn, & Partington, 1995). The only motivation for staff was concern that "If I don't do this, the child could lose her finger."

Under the leadership of two of Tanya's nurses, the new skills and knowledge necessary for leech therapy were rapidly acquired and communicated. This included the anatomy and physiology of the leech, medical/surgical rationale for leech therapy, procedure of leech application, ensuring attachment, storage and disposal, and obtaining a continual supply of leeches. By the end of the first postoperative day, written instructions shown in Table 1 had been developed using various resources, which included physicians, veterinary support technicians, and information from the company providing the leeches. These instructions supplemented bedside demonstrations and practice sessions of leech application and vascular assessment to ensure staff competency.

Pathophysiology

Leeches have been used to treat various ailments since ancient times. Today, the therapeutic effects of their bloodletting ability are well recognized. The medicinal leech (Hirudo medicinalis) is used to manage venous congestion following certain reconstructive and microsurgical procedures, such as digital replantation where sufficient arterial inflow exists (Leeches U.S.A. Ltd., 2002). The leech imitates the role of venous circulation at the site of replantation. The leech bite site provides an alternative for blood drainage until functioning collateral vessels are formed (Yurevich, 2002).

The leech is uniquely equipped to perform this task. Its mouth is located on the narrower, anterior end and has three sharp jaws with hundreds of teeth that produce a Y-shaped bite (Golden et al., 1995). The bite itself is pain free due to the naturally occurring local anesthetic in the leech's saliva (Kocent & Spinner, 1992). One bite removes about five milliliters of blood. Once satiated, the leech releases its bite and falls off the skin. The consumed blood is digested by the naturally occurring bacterium in the leech's gut.

The main therapeutic benefit of the bite results from the release of salivary secretions containing pharmacologically active substances. Table 2 lists the substances secreted in leech saliva and their function. Hirudin, hyaluronidase, and a histamine-like vasodilator work together to permit the site to ooze blood and other tissue fluid continuously for an average of 6 hours after the leech detaches (Yurevich, 2002). This oozing is essential to a successful surgical outcome. Oozing ensures minimal swelling by providing a route for adequate venous outflow until new venous growth occurs. At the same time it allows the fragile arterial anastomosis to heal. In Tanya's case, the need to protect the finger from swelling was especially important since no veins could be reattached and only the ulnar digital artery could be re-connected. Scrubs with heparin (100 U/ml) were performed to encourage bleeding by keeping the finger clean of any accumulating or clotted blood (Leeches U.S.A. Ltd., 2002).

Family Matters

Given the unusual nature of the therapy and the trauma associated with the injury, anxiety and fear were dominant emotions expressed by both Tanya and her parents. The family's limited experience outside their rural home environment and the accident occurring under parental supervision compounded the stress experienced with the health care interventions. Strategies to support coping included those commonly associated with family-centered care such as consistent nurses, private room with both parents rooming-in, and nursing care scheduled to respect family home routines and the need for downtime. Initially, the parents joined the nurses in learning about leeches and contributed to the assessment and management of their daughter's pain and comfort. Over time and in anticipation of discharge, they progressed to oral medication administration, dressing changes, and splint and sling application.

Surprisingly, Tanya was not afraid of the leeches. She was more concerned with the pain associated with dressing changes. In addition to medicating for pain, measures to promote coping were provided. Distinct time for medically related play with designated opportunities for developmentally appropriate activities was provided under the guidance of a psychologist and the hospital pre-school teacher. Because mobility is a defining characteristic of her developmental stage, supervised ambulation and a wagon reserved for her sole use were part of her care (Wong, 1997). No leeches were applied during ambulation. Keeping a 3-year-old's injured finger elevated and in her hand splint at all times demanded ingenuity and close monitoring. An IV pole outfitted with a small sling to hold her hand upright was adapted for her use. The pole's decorations were quite admired by the staff and helped provide distraction while encouraging the use of the sling.

The Rest of the Story

Tanya remained in the hospital for 19 days. Nursing assessments of her finger occurred every one to two hours and leeches were applied as necessary (on average every four hours) until postoperative day #17. She received a total of seven units of PRBCs. A cuffed central line was placed on postoperative day 8 to provide venous access after peripheral sites had been exhausted and the need for blood products, pain medication and antibiotics continued. The cuffed line provided benefits such as eliminating the trauma associated with needles and "sticks," increasing mobility and use of her left hand and fingers, and securing discrete placement out of reach of a young child's exploration. Preventing vasoconstriction and maximizing circulation to the replanted finger continued to be of prime importance. In the hospital this was achieved by room temperature controls, providing a caffeine-free diet and restriction on parental smoking in the hospital environment.

A family meeting was held prior to discharge to discuss continuing care needs and identify community resources to provide dressing changes and medical supervision for signs of insufficient vascular supply and infection of the replanted finger (see Figure 1). Three weeks after her discharge, Tanya returned for an ambulatory surgical procedure to remove the wire supporting the replanted finger.

[FIGURE 1 OMITTED]

The Lesson Learned

Tanya's case illustrates the complex, dynamic process of day-to-day nursing. More specifically, this case describes a nursing staff's implementation of newly acquired skills and knowledge to meet the challenges of a nonconventional therapy. While focusing on mastery of leech therapy, the nurses also used principles of pediatric nursing care to facilitate patient and family coping and adaptation to hospitalization and the required health care interventions. The document, "Tanya's Care" (see Table 1), became the basis for a written protocol for leech therapy. Overtime, the nurses' sense of accomplishment in mastering new skills and knowledge along with the satisfaction of the child's recovery supplanted their initial reluctance and aversion to leech therapy.
Table 1. Tanya's Care

Indicators for Leech Therapy

* Finger becomes dusky on any portion of the finger tip.

* Capillary refill is too brisk (less than 2-3 seconds at finger tip).

* Blood is not continually oozing.

Application of Leech

* Follow universal precautions.

* Remove leech from container with tweezers and place on cap of
specimen cup.

* Use tweezers to find the head of the leech (pointy part that moves
searching for blood).

* Put the head on finger tip at the site of the removed nail bed (may
need to nudge into position).

* Watch for head to latch on; its mouth will become circular like a
suction-cup. The leech will start to swell up and cannot be moved by
pushing. This prevents the leech from migrating down finger into
dressing.

Removal of Leech

* Never pull the leech off. You will damage the finger tissue or risk
contamination of the bite with regurgitated bacteria from the leech's
gut.

* The leech should fall off on its own within 15-30 minutes.

* Once removed, place leech in a specimen cup filled with 70% alcohol.

* Dispose of leech according to agency protocols for blood
contaminated materials.

Bleeding and Circulation

* Assess for bleeding every 1 to 2 hours to ensure continuous oozing.

* Assess color of replanted tip with neurovascular checks every 2
hours.

* Monitor hemoglobin/hematocrit for appropriate levels.

Heparin Scrubs

* Perform every 2 hours with Q-tips and 100 U/mi heparin and after
leech removal.

* Wipe off clots and clean finger in order to see as much of distal
portion of the right middle finger as possible.

Dressing Changes

*  Perform a complete dressing change, removing dressing all the way
down to the base of the finger BID.

* Give pain medication prior to dressing change.

* Redress hand so splint will have a good fit; make sure finger tip
does not touch the end of the splint.

Leech Storage and Care

* Store leeches in a suction canister filled with 900 ml sterile water
and 1 ml special saline solution (available from veterinary support
technician). Keep canister in a secured, cool, dark place in patient's
room.

* Open vent to provide ventilation.

* Cover vent with gauze to prevent leeches from escaping.

* Change water in canister 2-3 times a week.

* Page the veterinary support technician for assistance.

Table 2. substance Secreted in Leech Saliva and Their Function

Substance       Function

Hirudin         Potent, specific inhibitor of thrombin; serves as a
                anticoagulant.

Vasodilator     Histamine-like substance that increases the diameter of
                blood vessels and promotes blood flow.

Hyaluronidase   Aids in the breakdown of connective tissue, thus
                fostering the flow of blood and fluids from affected
                areas.

Anesthetic      Produces pain-free bite.


References

Golden, M.A., Quinn, J.J., & Partington, M.T. (1995). Leech therapy in digital replantation. AORN Journal, 62, 364-375.

Kocent, L.S., & Spinner, S.S. (1992). Leech therapy: New procedures for an old treatment. Pediatric Nursing, 18, 481-483, 542.

Leeches U.S.A. Ltd. (2002.) Medicinal leeches. Westbury, NY. Retrieved 5/27/02 from http://www.leechesusa.com

Utley, D.S., Koch, R.J., & Goode, R.L. (1998). The failing flap in facial plastic and reconstructive surgery: Role of the medicinal leech. Laryngoscope, 108, 1129-1135.

Wong, D.L. (1997). Whaley & Wong's essentials of pediatric nursing. St. Louis: Mosby.

Yurevich, S. (2002). The beneficial bite. Retrieved 8/14/02 from http://www. geocities.com/leechlady5/

Submitted by:

Marilu Dixon, MSN, RN, PNP

Advanced Practice Nurse I

Children's Medical Center

University of Virginia Health System

Charlottesville, VA
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Title Annotation:pediatric intensive care unit
Author:Dixon, Marilu
Publication:Pediatric Nursing
Date:May 1, 2003
Words:2378
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