Hirudotherapy for neonatal limb ischemia during ECMO support: A word of caution

Abstract

Introduction: Disordered coagulation, clot formation and distal limb ischemia are complications of extracorporeal membrane oxygenation (ECMO) with significant morbidity and mortality. Medicinal leech therapy (hirudotherapy) has been attempted in plastic and orthopedic surgeries to improve venous congestion and salvage ischemic flaps. To our knowledge this has not been reported in pediatric cardiac surgery or during ECMO support. We present a complex neonate whose ECMO course was complicated by distal limb ischemia for whom leech therapy was attempted.Patient and Intervention: A 2-week-old 2.7 kg infant required ECMO support secondary to perioperative multiorgan system dysfunction following repair of critical coarctation and ventricular septal defect. Despite systemic anticoagulation, his clinical course was complicated by arterial thrombus, vasopressor-induced vascular spasm and bilateral distal limb ischemia. Medicinal leech therapy was tried after initially failing conventional measures.Result: Following the third leech application, this patient developed significant hemorrhage from the web space adjacent to the left great toe. An estimated 450 ml of blood loss occurred and more than 300 ml of blood product transfusions were required. He ultimately progressed to irreversible systemic end organ dysfunction and comfort care was provided. Conclusion:The use of medicinal leech therapy in pediatric cardiac surgery may be considered to minimize the consequences of advanced limb ischemia and venous congestion. However, this should be used with caution while patients are systemically anticoagulated during ECMO support. A directed review is presented here to assist in determining optimal application and potential course of therapy.

Hirudotherapy for limb ischemia in the pediatric intensive care unit: A retrospective observational cohort

“…We previously reported a neonate requiring ECMO who developed severe hemorrhage with hirudotherapy for limb ischemia (patient 7) ( 34 ). This current paper reviews a series of seven critically ill children with acute limb ischemia in whom medicinal leech therapy was attempted for limb salvage.…”

“…Data was divided into a pre-leech phase (3 days), leech phase (duration of hirudotherapy plus 1 day), and post-leech phase (2 days). The leech phase extended one day beyond leech removal to account for additional bleeding based on our experience with additional side effects and other available literature ( 6 , 34 ). The best practices integrated informatics core assisted with data extraction from the electronic health record to improve efficiency.…”

“…No established guidance for this use exists, and the same salivary enzymes that dictate leech's therapeutic potential also predispose to adverse effects (2,(27)(28)(29)(30)(31)(32)(33). We have previously reported a neonate requiring extracorporeal membrane oxygenation (ECMO) on whom hirudotherapy was attempted for limb ischemia, resulting in massive hemorrhage (34).…”