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Annals of Cardiac Anaesthesia Annals of Cardiac Anaesthesia Annals of Cardiac Anaesthesia
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Table of Contents
LETTER TO EDITOR  
Year : 2012  |  Volume : 15  |  Issue : 1  |  Page : 83-85
Off-pump cardiac surgery (OPCAB) in a patient with recent leech therapy


1 Medanta Institute of Critical Care and Anaesthesiology, Medanta The Medicity Sector 38, Gurgaon, Haryana, India
2 Medanta Heart Institute, Medanta The Medicity, Gurgaon, Haryana, India

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Date of Web Publication5-Jan-2012
 

How to cite this article:
Sawhney R, Juneja R, Rawat RS, Mehta Y, Trehan N. Off-pump cardiac surgery (OPCAB) in a patient with recent leech therapy. Ann Card Anaesth 2012;15:83-5

How to cite this URL:
Sawhney R, Juneja R, Rawat RS, Mehta Y, Trehan N. Off-pump cardiac surgery (OPCAB) in a patient with recent leech therapy. Ann Card Anaesth [serial online] 2012 [cited 2019 Dec 11];15:83-5. Available from: http://www.annals.in/text.asp?2012/15/1/83/91468


The Editor,

Leech therapy has been successfully used for the treatment of cardiovascular diseases such as arterial hypertension, angina pectoris, myocardial infarction. These leeches are placed externally on the appropriate parts of the body on the so-called specific biologically active points. During feeding leeches secrete pharmacologically active substances into the wound. Hirudin is the prominent constituent of the leech saliva which inactivates fibrin bound thrombin and dissolves blood clot.

A 60-year-old female weighing 114 kg presented in the emergency room with complaints of chest pain on moderate exertion. She was a known case of hypertension and on regular medication. Systemic examination was unremarkable except that there were four red inflammatory skin lesions of 1.5 cm×1.5 cm over her back in the thoracic region [Figure 1]. She had taken leech therapy for her cardiac ailment till 3 days before her admission to our centre. Routine hematological and biochemical investigations were within normal limits Coagulation parameters including bleeding time, clotting time, prothrombin time, activated partial thromboplastin time and platelet count were within normal limits. Echocardiography showed left ventricular ejection fraction of 60%. Coronary angiography revealed triple vessel disease. She was not on any antiplatelet agents for the last 7 days.
Figure 1: Leech bite lesions at the back of the patient

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The patient was premedicated with oral lorazepam 2 mg and pantoprazole sodium 40 mg on the night before surgery. Anesthesia was induced with sodium thiopentone, fentanyl citrate, and vecuronium bromide (0.15 mg/kg). One milligram of morphine in 3 ml of normal saline was injected in L 2-3 subarachnoid space in lateral decubitus position using a 25G spinal needle after intubation. Anesthesia was maintained with intermittent doses of fentanyl citrate, vecuronium bromide, and isoflurane in 50% oxygen in air. Intraoperative monitoring included ECG with ST segment analysis, oxygen saturation, end-tidal carbon dioxide, temperature, urine output, arterial pressure, pulmonary artery and central venous pressures, cardiac output, arterial blood gas analysis, and activated coagulation time (ACT). Off-pump coronary artery bypass (OPCAB) grafting was performed. Heparin sulfate 2 mg/kg was administered after dissection of the LIMA and reversed with protamine sulfate in a 1:1 ratio. ACT after heparin was more than 300 seconds and 135 seconds after reversal with protamine.

The intraoperative period remained uneventful with blood loss of 700 ml which was replaced with 500 ml of Ringers lactate and 1200 ml of hydroxyethyl starch. The patient was transferred to the recovery room and the trachea was extubated after 6 hours of ventilation. Postoperative chest tube drainage was 400 ml. Anticoagulation in the form of heparin 5000 units subcutaneously and aspirin 75 mg per oral was started after chest tube removal. Postoperatively she was pain free for 24 hours and then analgesia was achieved with intermittent doses of tramadol hydrochloride (1.5 mg/kg). Postoperatively, coagulation parameters remained within normal limits. She was discharged from the hospital on the fifth postoperative day.

Hirudotherapy is used for cardiovascular diseases such as arterial hypertension, angina pectoris, myocardial infarction. The prolonged bleeding after a leech bite is due to the action of factors in the leech saliva left in the bite, which include histamine-like vasodilators, hirudin (a potent antithrombin), hyaluronidase, and calin (a platelet aggregation inhibitor). [1],[2],[3] Interaction between exposed collagen and platelet and/or von Willebrand factor is one of the initiating events for thrombus formation at the site of damaged endothelium. Interference with this mechanism may provide an antithrombotic potential. Calin specifically inhibits human platelet aggregation induced by collagen and also inhibits platelet adhesion. [4] Bleeding from a leech bite wound can persist for a mean of 10 hours and as long as 7 days. [2] Although the patient had stopped leech therapy 3 days prior to surgery and the elimination half life of hirudin is 0.6-2 hours, as a precautionary measure, we preferred to give morphine through lumbar spinal route rather than thoracic epidural with a catheter for pain relief. In the past, we have shown subarachnoid morphine to be as effective as thoracic epidural analgesia (TEA) in OPCAB. [5] Also we had found significant improvement in lung function in obese patients with TEA after OPCAB [6] so the subarachnoid block for postoperative analgesia was preferred in this patient.

A patient who has undergone leech therapy can be identified after taking history and detailed local examination as our patient had typical lesion of leech bite. Contamination with pathogenic microorganisms may result in erysipelas and submucosal abscess. A possibility of Aeromonas hydrophila Scientific Name Search  infection has been reported. This is found in the flora of the leech intestine and has been grown from H medicinalis. Effective antibiotic treatment against Aeromonas is composed of third-generation cephalosporins, aminoglycosides, trimethoprim-sulfamethoxazole, and ciprofloxacin; however, there is resistance to first-generation cephalosporins and penicillin because of β-lactamase production. [7] These patients can have anemia, history of vasovagal syncope because of blood loss through the site of the bite resulting in low blood volume. Also one has to be careful about the coagulation parameters as hirudin binds directly to thrombin without need of a cofactor or enzyme, inhibiting all the proteolytic functions of thrombin. This inhibition includes actions on fibrinogen, factors V, VIII, and XIII, and platelets. [8] No specific tests are available to check the effect of hirudins on humans. Kumar [9] reported a case with coronary artery disease, on aspirin who developed gastrointestinal hemorrhage and severe anemia after leech therapy for knee pain despite normal coagulation parameters.

Leech treatment generally does not cause changes in systemic coagulation profile. However, excessive leech use may result in bleeding diathesis and deranged prothrombin time, international normalized ratio and activated partial thromboplastin time requiring FFP and platelet transfusions. [10] The wound of leech bite may be a source of infection so appropriate antibiotic coverage is recommended. The choice of regional anesthesia would depend upon the coagulation profile and the time of last leech therapy. Potential coagulopathy requiring blood product usage needs to be kept in mind in a cardiac surgical patient.

 
   References Top

1.Adams SL. The emergency management of a medicinal leech bite. Ann Emerg Med 1989;18:316-9.  Back to cited text no. 1
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2.Munro R, Hechtel FO, Sawyer RT. Sustained bleeding after a leech bite in the apparent absence of hirudin. Thromb Haemost 1989;61:366-9.  Back to cited text no. 2
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3.Conforti ML, Connor NP, Heisey DM, Hartig GK. Evaluation of performance characteristics of the medicinal leech (Hirudo medicinalis) for the treatment of venous congestion. Plast Reconstr Surg 2002;109:228-35.  Back to cited text no. 3
[PUBMED]    
4.Deckmyn H, Stassen JM, Vreys I, van Houtte E, Sawyer RT, Vermylen J. Calin from Hirudo medicinalis, an inhibitor of platelet adhesion to collagen, prevents platelet-rich thrombosis in hamsters. Blood 1995;85:712-9.  Back to cited text no. 4
[PUBMED]  [FULLTEXT]  
5.Mehta Y, Kulkarni V, Juneja R, Sharma KK, Mishra Y, Raizada A, et al. Spinal (subarachnoid) morphine for off-pump coronary artery bypass surgery. Heart Surg Forum 2004;7:E205-10.  Back to cited text no. 5
[PUBMED]  [FULLTEXT]  
6.Sharma M, Mehta Y, Sawhney R, Vats M, Trehan N. Thoracic epidural analgesia in obese patients with body mass index of more than 30 kg/m 2 for off pump coronary artery bypass surgery. Ann Card Anaesth 2010;13:28-33.  Back to cited text no. 6
[PUBMED]  Medknow Journal  
7.Bickel KD, Lineaweaver WC, Follansbee S, Feibel R, Jackson R, Buncke HJ. Intestinal flora of the medicinal leech Hirudinaria manillensis. J Reconstr Microsurg 1994;10:83-5.  Back to cited text no. 7
[PUBMED]  [FULLTEXT]  
8.Stringer KA, Lindenfeld J. Hirudins: Antithrombin anticoagulants. Ann Pharmacother 1992;26:1535-40.  Back to cited text no. 8
[PUBMED]    
9.Kumar N, Mohindra R, Mohan B, Wander GS. Gastrointestinal bleed after leeching in a patient on aspirin therapy. Indian J Gastroenterol 2005;24:170.   Back to cited text no. 9
[PUBMED]    
10.Kose A, Zengin S, Kose B, Gunay N, Yildirim C, Kilinc H, et al. Leech bites: Massive bleeding, coagulation profile disorders, and severe anemia. Am J Emerg Med 2008;26:1067.e3-6.  Back to cited text no. 10
    

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Correspondence Address:
Yatin Mehta
Medanta Institute of Critical Care and Anaesthesiology, Sector 38, Gurgaon, Haryana 122 001
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/0971-9784.91468

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