Hirudotherapy for limb ischemia in the pediatric intensive care unit: a retrospective observational cohort
Resch JC, Hedstrom R, Steiner ME, Said SM, Somani A (2023) · Frontiers in Pediatrics · n=7
Perfil del estudio
- Diseño
- single-center, retrospective observational cohort using institutional database query (University of Minnesota, M Health Fairview Masonic Children's Hospital)
- Tamaño de la muestra (n)
- 7
- Intervención
- Medicinal leech therapy applied to pediatric patients (<18 years) with refractory limb ischemia in the pediatric intensive care unit; mean time-to-application 3 days, mean duration of use 3.9 days
- Comparador
- No randomized comparator; descriptive analysis of outcomes against natural history of refractory limb ischemia
- Punto final primario
- Limb salvage outcomes (preservation vs amputation), mortality, bleeding complications, transfusion requirements, and vasoactive-inotropic score
- Resultado primario
- Mortality 57% (4/7), all secondary to multi-organ failure; in 3 surviving patients, 4 of 5 treated limbs required at minimum partial amputation; 5 patients had leech therapy discontinued due to bleeding; transfusion requirements increased predictably with leech use
- Duración del seguimiento
- until hospital discharge or death
- PMID
- 36683785
Hallazgos clave
- First published US pediatric ICU cohort of leech therapy for refractory limb ischemia (5 congenital heart disease, 2 viremic shock)
- Authors explicitly recommended AGAINST routine use of hirudotherapy for acute limb ischemia from arterial malperfusion in the pediatric ICU
- 57% mortality rate (all multi-organ failure); 4 of 5 treated limbs in survivors required partial or complete amputation
- Bleeding led to discontinuation of leech therapy in 5/7 patients - the dominant adverse event in this critically ill population
- Higher pre-application vasoactive-inotropic scores suggest vasoconstrictive arterial malperfusion - a pathophysiology poorly suited to leech-mediated venous decongestion
Limitaciones
- Very small sample (n=7) and retrospective design preclude inferential statistical analysis
- Heterogeneous primary diagnoses (congenital heart disease, viremic shock) confound limb-outcome interpretation
- No standardized leech-application protocol across cases - variable timing, count, and duration
- Critically ill pediatric population at high baseline risk - results may not generalize to less acutely ill patients or to adults
- No direct comparator arm; outcomes cannot be attributed to leech therapy vs underlying disease severity
Implicaciones clínicas
Resch 2023 is the only modern published pediatric ICU cohort of leech therapy for limb ischemia and provides explicit evidence against routine use of hirudotherapy for arterial malperfusion in critically ill children. The 57% mortality and 80% amputation rate among surviving limbs argue strongly that arterial-cause ischemia is mechanistically inappropriate for leech-based intervention. For pediatric intensivists, this cohort supports a strict indication of pure venous congestion (with intact arterial supply) before considering leech application, and reinforces the importance of protocolized criteria for start, stop, and adverse-event monitoring. The trial is included here as a clinically important negative result that helps define the boundaries of appropriate leech-therapy use.
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