Resch Joseph C, Hedstrom Rachel, Steiner Marie E, Said Sameh M, Somani Arif
Department of Pediatric Critical Care, University of Minnesota, M Health Fairview Masonic Children's Hospital, Minneapolis, MN, United States.
Department of Pediatric Cardiac Surgery, University of Minnesota Masonic Children's Hospital, Minneapolis, MN, United States.
Front Pediatr. 2023 Jan 5;10:1011171. doi: 10.3389/fped.2022.1011171. eCollection 2022.
Acute limb ischemia due to microvascular malperfusion may be refractory to initial therapies. Medicinal leech therapy (hirudotherapy) has been attempted in plastic and reconstructive surgery to improve venous congestion in ischemic flaps; however, there are minimal reports related to ischemia secondary to arterial malperfusion. We evaluated a pediatric cohort from an academic intensive care unit with refractory limb ischemia in whom hirudotherapy was attempted to elucidate its use and outcomes.
Institutional patient database was queried to identify pediatric patients (<18 years) who received hirudotherapy in the pediatric critical care unit and met inclusion/exclusion criteria. Patient charts were evaluated for indices including demographics, primary disease, coagulative status, vascular access, vasoactive medication dosing, bleeding, leech use, limb and mortality outcomes. Data was evaluated to identify trends or suspected impact on outcomes.
Hirudotherapy was used in 7 patients for limb ischemia, 5 with congenital heart disease, and 2 others with viremic shock. Time to leech application following recognition of ischemia averaged 3 days, with duration of use averaging 3.9 days. Five patients discontinued therapy due to bleeding. Mortality rate was 57%, all secondary to multiorgan failure. In 3 surviving patients, 4 of 5 treated limbs resulted in at minimum partial amputation. Vasoactive-inotropic score tended higher prior to leech application, suggesting a vasoconstrictive pathway for arterial malperfusion. No identifiable trends appeared associated with salvaged limb or adverse effects. Blood loss predictably increased with leech application, as did total transfusion requirement.
This case series establishes baseline data for use of hirudotherapy in critically ill children with acute limb ischemia caused by arterial malperfusion. Based on this retrospective cohort, we cannot recommend routine use of hirudotherapy for acute limb ischemia from arterial malperfusion in the pediatric intensive care unit. Application of leeches should be aligned with a protocol defining start and stop parameters, standardized leech utilization, and monitoring for adverse outcomes. Future study would benefit from consensus definitions of study outcomes, including perfusion recovery, tissue/limb salvage and bleeding manifestations. Additional prospective studies are needed prior to any standard or systematic recommendations for use.
微血管灌注不良所致的急性肢体缺血可能对初始治疗无效。药用蚂蟥疗法（水蛭疗法）已用于整形和重建手术，以改善缺血皮瓣的静脉淤血；然而，关于动脉灌注不良继发缺血的报道极少。我们评估了来自一所学术重症监护病房的一组难治性肢体缺血的儿科患者，尝试用水蛭疗法以阐明其应用及疗效。
查询机构患者数据库，以识别在儿科重症监护病房接受水蛭疗法且符合纳入/排除标准的儿科患者（<18岁）。评估患者病历的指标包括人口统计学、原发疾病、凝血状态、血管通路、血管活性药物剂量、出血情况、水蛭使用情况、肢体及死亡率结果。对数据进行评估以确定趋势或对结果的潜在影响。
7例患者因肢体缺血接受水蛭疗法，其中5例患有先天性心脏病，另外2例患有病毒血症性休克。识别出缺血后至应用水蛭的平均时间为3天，使用持续时间平均为3.9天。5例患者因出血而停止治疗。死亡率为57%，均继发于多器官功能衰竭。在3例存活患者中，5条接受治疗的肢体中有4条至少进行了部分截肢。应用水蛭前血管活性-正性肌力评分往往较高，提示动脉灌注不良存在血管收缩途径。未发现与挽救肢体或不良反应相关的可识别趋势。随着水蛭的应用，失血量和总输血需求量均如预期增加。
本病例系列为在患有由动脉灌注不良引起的急性肢体缺血的危重症儿童中使用水蛭疗法建立了基线数据。基于这个回顾性队列，我们不建议在儿科重症监护病房对动脉灌注不良所致的急性肢体缺血常规使用水蛭疗法。水蛭的应用应符合定义开始和停止参数、标准化水蛭使用及监测不良结果的方案。未来的研究将受益于对研究结果的共识定义，包括灌注恢复、组织/肢体挽救和出血表现。在进行任何标准或系统性使用建议之前，还需要更多的前瞻性研究。
