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SEPTEMBER 1995, VOL 62, NO 3

Golden Quinn Partington 9

Leech Therapy in Digital Replantation

L eech therapy was first used in Egypt around


1500 BC to treat a range of ailments from
nosebleeds to gout. In the Middle Ages, Anglo-
Saxon physicians were called “leeches”
because of their fondness for using these versa-
tile creatures in their treatments.’ After a long period
of disuse, leeches became popular again in the 1960s
because of the successes demonstrated by plastic and
reconstructive surgeons in treating tissue compromise
quently; it can live up to 200 days between feedings.
Perioral glands in the leech’s mouth secrete sali-
va containing the chemical hirudin, a potent natural
anticoagulant that prevents or reverses blood coagu-
lation in the leech’s The therapeutic effect of a
leech bite is not from the volume of blood ingested
but from the continuous bleeding from the bite
wound after detachment.6 Continuous oozing from
the bite site also may prevent infection from the bac-
from venous congestion.2 These successes have teria Aeromonus hydrophilia, a normal flora present
prompted surgeons to use leeches in microsurgical in the leech’s gut. The routine use of prophylactic
procedures involving digital replantations.3 antibiotics during leech therapy also prevents infec-
tion that may be caused by the ba~teria.~ The leech’s
LEECnAlYATOMYANDPWSlOW6Y saliva contains two other notable components: a
There are hundreds of varieties of leeches, but local anesthetic, which accounts for the painless
only four varieties are used for medicinal purposes. attachment of the leech when it begins to feed, and a
The type most commonly used in microsurgery is vasodilator, which promotes blood flow during the
Hirudo medicinalis (Figure l), which is native to feeding period.
southeast Asia and E ~ r o p e This
. ~ type of leech is
dark brown or green in color and measures 12 cm to DIGCTAL - A m CONSIDERATIONS
20 cm when stretched out. Both ends of the leech The primary treatment for traumatic multiple
have suckers that help it remain attached while feed- digit amputations is digital replantation.8 Some
ing. The mouth on the anterior, narrower end has patients, however, refuse digital replantation because
three sharp jaws that produce a Y-shaped bite. Hiru- of the long, technically involved microsurgical pro-
do medicinalis is a hermaphrodite that feeds infre- cedure and the lengthy rehabilitation and absence
from the workplace? The goal of
digital replantation is to restore
A B S T R A C T function to the patient’s fingers,
This article presents a protocol for the perioperative care of not simply to pekorm a technical-
patients undergoing digital replantation, which is the most common ly successful surgery.
microsurgical procedure performed today. Venous congestion, a Ischemia. Patient access to a
common complication of digital replantation, often has been treated replantation center plays a vital
through surgical exploration and creation of atteriovenous anasto- role in a successful surgical out-
mosis. Leech therapy, however, is experiencing a resurgence among come. Only one fifth of traumatic
surgeons as an alternative method for treating venous congestion. amputation victims reach a sur-
This article discusses the anatomical, physiological, and clinical indi- geon in time for digital replanta-
cations and methods of leech therapy in digital replantation. AORN J tion.1° Ischemia time (ie, the
62 (Sept 1995) 364-375. amount of time the amputated

t M A R Y A N N G O L D E N , R N ; J E A N N E J . Q U I N N , R N ; M A R S H A L L T . P A R T I N G T O N , YD

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part is without a blood supply) is useful in treating arterial prob-


a critical factor in determining the lems. Proper care must be taken
likelihood of a successful digital to prevent edema, tissue necrosis,
replantation. Digits have survived and thrombosis. If this regimen is
cold ischemia times of 24 to 36 not followed, the affected part
hours and warm ischemia times of may not survive.
eight to 10 hours.'I Cooling slows
. O n e study supports the
down cellular metabolism by 50% ~i~~~~ 1 Sketch of 0 H&,do medim important role of leeches in treat-
for each 10" C drop in tempera- cinalis leech. (Figures 1, 2, and 3 ing congestion; leeches
ture, thus lengthening the time a courtesy of David low, MD, can extract up to six times their
body part can survive without its Philadelphia) body weight before detaching
blood supply. An amputated digit, spontaneously. The study also
therefore, should be packed in ice states that if a leech attaches or
until treatment is initiated. sucks slowly, the prognosis for the replanted digit is
Arteriovenous anastomosis. The availability of poor, even though the color of the replanted digit
both an artery and a vein during replantation of an may appear satisfactory at the time.I4 The majority
amputated digit is a favorable situation. Arterial of patients faced with the likelihood of digital loss
anastomosis supplies blood inflow to the digit and from venous congestion readily accept leech thera-
venous anastomosis provides blood outflow. If, dur- py. Experienced and supportive nursing staff mem-
ing the replantation process, inadequate veins exist bers who can allay patients' fears are critical to the
for a primary arteriovenous anastomosis, the surgeon success of leech therapy.
usually attempts a vein graft. At least one, and
preferably two, veins should be repaired for each EMERGENCY ADMISSION OF THE PATIENT
arterial anastomosis." AN AMPWATED DIGIT
Crush injuries to the hand are particularly high- Preoperative care of the patient requiring digital
risk situations because contusions to the dorsal veins replantation begins in the emergency department
of the fingers severely limit the ability to perform (ED) of the nearest replantation center. When the
reanastomosis procedures on those vessels. The patient arrives at the ED, the amputated part accom-
veins in the distal part of the finger are quite small panies him or her. The severed digit should arrive at
(ie, less than 1 mm in diameter).13 With a crush the ED wrapped in a slightly dampened piece of
injury, the surgeon often anticipates venous insuffi- gauze or paper towel that is placed in a clean plastic
ciency and begins leech therapy to remove engorged bag or waterproof container. The emergency medical
blood from the digit. services personnel ensure that the bag or container is
Venous congestion. Time is the critical element placed in a larger container that holds water and
in reestablishing vascularity in the replanted digit enough ice to keep the water cold during transport to
when signs of venous congestion (ie, arterial the hospital.l5
obstruction,
thrombosis,
necrosis, loss
of the digit)
appear (Figure
2). Health care
providers must
differentiate
between ven-
ous and arterial
congestion be-
fore leech ap-
plication be-
cause a leech
often is not Figure 2 Indicators of arterial occlusion (left) and venous occlusion (right).

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Our facility has established specific guidelines be attached to the microscope, and both instruments
and protocols for emergent care of the trauma patient should be draped in a sterile fashion to allow the
requiring digital replantation. The surgeon obtains a scrub person and other members of the surgical team
comprehensive medical history and arranges all con- to view the procedure. The OR bed should have a
sultations concerning the patient’s current medical swivel base that enables it to rotate 90 degrees to
status. The ED nurse performs specific patient inter- facilitate movement of the microscope base into suit-
ventions, including able positions. At our hospital, a gel-filled mattress
identifying patient allergies, is placed on the OR bed to protect the patient’s bony
starting an IV line to deliver pain medication and prominences from undue pressure during the long
a broad spectrum antibiotic (eg, cephalosporin), procedure.
and
performing a physical assessment to determine INTR&OPERATWEPAllElWCARli
other problems (eg, head injury). Although this surgical procedure can begin
The surgeon orders 600mg aspirin in supposito- before the patient arrives in the OR, the circulating
ry form and keeps the patient NPO in preparation for nurse realizes that the patient is his or her priority.
surgery. Aspirin acts as an antiagglutinate on When the patient arrives in the OR suite, the circu-
platelets and begins the anticoagulation process to lating nurse checks for informed surgical and blood
prevent venous congestion. The surgeon initiates transfusion consents, laboratory test results, and
laboratory studies, x-rays, and any other emergency appropriate x-ray films. To alleviate some of the
procedures necessary.I6 patient’s anxiety, the circulating nurse reassures the
patient that family members will be kept informed of
OR PREPARATWN his or her progress at two-hour intervals. The circu-
When planning for the replantation procedure, lating nurse explains to the patient what to expect in
surgeons may bring the amputated part to the OR the OR (eg, cool environment, bright lights, hemody-
before the patient arrives. This is one of the few namic monitors). After the patient arrives in the OR,
times in which surgery can begin before the patient the circulating nurse explains OR procedures as they
arrives in the OR. The scrub person prepares a sterile occur (eg, placement of electrocardiogram leads,
table with a soft tissue set and basins. The soft tissue application of pneumatic compression stockings).
set includes During anesthesia induction, the circulating
hemostats, nurse assists the anesthesia care provider. Patients
iris scissors, undergoing digital replantation often have full
small dissecting scissors, stomachs and are at risk for regurgitation of stom-
fine-toothed forceps, ach contents into the lungs; therefore, a rapid-
a bone cutter, sequence induction may be performed. The anes-
curettes, and thesia care provider administers a rapid-acting
microsurgical instruments. anesthetic agent, followed by a muscle relaxant (eg,
The first team of surgeons washes, debrides, succinylcholine). The circulating nurse applies
and tags the neurovascular structures of the amputat- cricoid pressure to partially occlude the esophagus,
ed part, which is still in ice. Having the vessels ready which prevents aspiration during intubation.
for anastomosis to the stump decreases the overall Conscious intubation may be appropriate if the
ischemia time. The surgeons remove splintered bone patient has airway problems. In this situation, the
fragments with a bone cutter. Stainless steel surgical circulating nurse has a cart available that contains a
wires in the prepared bones (ie, osteosynthesis) per- flexible bronchoscope and a local anesthetic to
mit a tension-free anastomosis of vessels and nerves numb the patient’s airway and inhibit the gag reflex.
while maximizing length and function.I7 With conscious intubation the airway reflexes are
Before the surgical procedure begins, the circu- preserved, which allows the endotracheal tube to
lating nurse verifies the strength of the microscope pass through the patient’s vocal cords on inspira-
lens with the surgeons and cleans and attaches it to tion. Regional anesthesia, which requires that the
the microscope. The microscope should be double patient lie still, can be used but is not recommended
headed so the surgeon and assistant can view the sur- because of the length of the procedure.’*
gical field simultaneously. A videotape camera can After induction, the circulating nurse provides

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the following items to the anesthesia care provider:


preoperative antibiotics (1 gm cefazolin sodium is
the antibiotic of choice if the patient has no aller-
gies),
an IV infusion pump for infusion of dextran 40
later in the procedure,
5,000 U of heparin, and
a temperature probe to monitor the patient's body
temperature.
The patient's core temperature should be greater
than 96.8" F (36" C). After induction, the circulating
nurse inserts a 14-Fr Foley catheter to monitor the
patient's urine output.
Figure 3 Artist's rendering of partial nail plate
SURGICAL PROCEDURE removal, used to prevent blood coagulation.
Two teams of surgeons and nurses work simul-
taneously to decrease the patient's time under anes-
thesia. In preparation for the digital replantation, the person should be ready to assist the surgeons with
scrub person opens a basic microsurgical tray and any number of procedures (eg, reexploration, vein
provides the surgeon with specific instruments. A graft, release of skin sutures, partial nail plate re-
microsurgical tray includes moval, application of leeches).
microforceps, Partial nail plate removal can be a useful
microscissors, adjunct in digital replantation. The surgeons accom-
microneedle holders, plish this by introducing a hemostat under the
small bulb irrigators with cannulae, and patient's fingernail to elevate the nail plate from the
vessel dilators. nail bed (Figure 3). The exposed nail bed promotes
All solutions in the surgical field must be venous drainage by allowing engorged blood to ooze
labeled. The solutions include heparinized saline (ie, from tissue when adequate venous channels are lack-
5,000 U heparin in 100 mL normal saline) for irriga- ing.I9 The goal of nail plate removal is to prevent
tion, 40 mg/mL lidocaine, and 30 mg/mL papaverine coagulation of blood on the nail bed and to encour-
hydrochloride to prevent muscle spasm. age continuous drainage. The scrub person assists in
The stump of the amputated digit is prepared in promoting the desired bleeding by gently rubbing the
the same manner as the patient's amputated part. exposed nail bed with a heparinized saline sponge. If
When the surgeons complete osteosynthesis, the leeches are to be used, the scrub person will assist
scrub person disposes of the cut ends of the stainless with leech application after the nail bed is rubbed
steel surgical wires used in the procedure. The surgi- with a heparinized saline sponge. A leech may also
cal wires are considered sharps and must be handled be applied at the site of digit reattachment.
properly after they are passed through the patient's Wound closure is achieved by reattaching the
bone to decrease the risk of puncture wounds to the digit and, therefore, closing the stump. To protect the
surgical team members. replanted digit, we use a minimal dressing. An iod-
The surgeons identify the patient's digital stump oform-impregnated nonadherent dressing is placed
arteries and the recipient digit arteries for potential on the wound with a bulky dry dressing of cotton
anastomosis. Arteries usually are repaired first to padding and plaster. Dressing changes should be
limit ischemia time and to aid in the identification of limited and inspection of the replanted digit should
viable veins. After the surgeons complete the arterial be done frequently to decrease the risk of compres-
anastomosis using 9-0 monofilament suture, the digit sion and constriction.
should be pink, indicating adequate arterial inflow. The patient usually is admitted to the postanesthe-
The scrub person provides the surgeons with another sia care unit (PACU) or surgical intensive care unit
9-0 monofilament suture when they are ready to (SICU) for 24 hours after surgery. Leeches applied to
begin the venous anastomosis. If there is poor the patient during replantation will accompany him or
venous flow after the venous anastomosis. the scrub her during transport to the PACU or SICU.

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Fluoroscein dye is area with a blanket, and using a heating lamp. Caffeine
(eg, coffee, tea, caffeinated sodas, chocolate) must be
eliminated completely from the patient’s diet to pre-
a useful method of vent vasoconstriction. Smoking is absolutely forbid-
den because the carbon monoxide and nicotine in
tobacco are potent vasoconstrictors.20Even second-
monitoring circulation hand smoke can cause failure of a digital replantation.
Circulation monitoring. Fluoroscein dye is a
useful method of monitoring circulation in a replant-
in a replanted digit. ed digit. After the surgeon injects fluoroscein sys-
temically through the patient’s IV line, it rapidly
penetrates all perfused tissue.21The clinical use of
fluorescein involves determining whether fluores-
cence occurs after fluorescein injection. An absence
The circulating nurse reports to the PACU of fluorescence indicates a lack of arterial inflow.
nurse that leeches are being used and will be trans- Prolonged fluorescence suggests a venous obstruc-
ported to the PACU attached to the patient’s tion. Fluorescence is measured by shining a hand-
replanted digit. Information that is pertinent to the held fluorimeter or an ultraviolet lamp on the
patient’s condition also is reported (eg, types, num- replanted digit and at a suitable control site on near-
ber of arterial and peripheral N lines; presence of by normal skin.22More important than absolute
Foley catheter; application of thermal regulating numbers generated by the fluorimeter is the relative
blankets if needed). The circulating nurse also change in fluorescence seen before injection and
informs the PACU nurse of where the patient’s fam- shortly after injection (ie, peak) and the subsequent
ily members are waiting. decrease in fluorescence, which indicates venous
clearance of the dye from the digit and eventual
-TlVE PATI= CARE renal excretion. It is the postoperative nurses’
The patient will have a Foley catheter and will responsibility to record the peak flow times and note
remain NPO for 24 hours postoperatively. This is a the fall-off times of the dye’s fluorescence at the site
critical time period during which most problems of reattachment. Fluorescein may cause nausea,
occur that may require the patient’s return to the OR. vomiting, and an allergic reaction (rare).
The patient is maintained on bed rest for five days Postoperative medications. Postoperative med-
because he or she is fully anticoagulated and, there- ications include an anticoagulant in the form of aspirin
fore, at increased risk for bleeding should he or she suppositories. Heparin also may be ordered for crush
fall when transferring out of bed or ambulating. A injuries but may be contraindicated in the presence of
private room is ideal but not essential to guarantee the other injuries (eg, head trauma). During surgery, the
patient a calm and quiet environment in which move- anesthesia care provider inserts a peripheral IV line
ment is kept to a minimum. The postoperative nurses and infuses a dextran 40 solution to serve as a volume
perform frequent vital signs and wound checks (ie, expander. Dextran 40 encourages vasodilation by
the digit’s color and temperature, amount of swelling, decreasing blood viscosity and inhibiting platelet
presence of a pulse). Other key nursing functions aggregation, which decreases venous thr0mbosis.2~
include pain control, promotion of vasodilation, and Dextran 40 is continued for a five-day period. Medica-
prevention of constriction on the surgical site. tions to control pain and prevent anxiety also are rou-
Vasoconstriction avoidance. In the immediate tinely ordered. Systemic antibiotics are important in
postoperative period, the PACU nurse promotes the postoperative period to help avoid wound infec-
venous drainage by elevating the affected part and by tions, particularly with the use of leech therapy.
avoiding direct pressure to it. A custom splint to main- Leeches. Emotional support and participation
tain elevation has been found to be quite effective in by family members contribute significantly to the
ensuring satisfactory elevation and preventing con- patient’s acceptance of leech therapy. Removal of
striction when patient compliance is unreliable. Vaso- psychological stress is very important during this
constriction also can be avoided by raising the room procedure. There should be a good understanding of
temperature to 78” F (25.5” C), covering the affected the mechanics of the treatments. The patient and

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attach to a host and suck blood. If a leech does not


show interest in attaching, a different leech should be
applied. If a second leech does not attach, the post-
operative nurse should consider the possibility of
“lazy leech syndrome.” This behavior is not actual
laziness but a reaction to the anesthetic agents that
have infiltrated its
Successful attachment depends on scrupulous
skin preparation. Ointments, old blood, and skin
antiseptics must be removed or the leech will not
attach to the area. The postoperative nurse must wear
gloves and use forceps to handle the leech. After the
site is cleansed with saline, a small needle puncture
Figure 4 Leeches applied to the fingers of a patient is made into the congested digit to initiate bleeding.
who has undergone digital replantation. The leech is then placed on the digit near the bleed-
ing site. The leech should move toward the blood,
attach firmly, bite, and then suck the patient’s
family members should be encouraged to voice fears blood.26 A drop of 10% dextrose solution can be
and concerns. Special consideration should be given used to encourage the leech to attach to the digit if
when leech therapy is used with pediatric patients. necessary. To keep the leech from roaming from the
Leeches usually are applied every two hours, or intended bite site, a tent of gauze dressing can be
as otherwise ordered by a physician. As venous con- constructed around the leech (Figure 4). The postop-
gestion resolves, this regimen often is relaxed to a erative nurse initially stays at the bedside to ensure
PRN basis. The postoperative nurse is responsible for that the leech does not crawl up into the dressing.
applying and removing leeches. The number of leech- Alternately, a paper cup with a hole in the bottom
es and application times are recorded by the nurse. allows the replanted digit to be inserted from under-
During leech therapy, the postoperative nurse closely neath and may serve to contain the leech and limit
monitors the patient’s hemoglobin, hematocrit, and migration away from the digit.
bleeding times. Approximately 50% of patients who If, after feeding, the leech does not detach spon-
undergo replantation require blood transfusions taneously, the nurse can touch the leech with a cot-
because the anticoagulation and continuous oozing ton tip dipped in alcohol to relax the leech bite.*’ The
from leech bites causes their hematocrit levels to nurse then kills the leech by placing it in a small con-
Leeches are stored in a freshwater solution in the tainer of alcohol. The leech is handled like biohaz-
pharmacy and an immediate supply may be kept in the ardous waste and disposed of in a container for cont-
patient’s room for ongoing use. Pretreating the live aminated items.
leech with antibiotics before application is presently
being tested to help minimize infection from RLllABlLllAllON
Aeromonas hydrophiliu, the potentially harmful bacte- When a replanted digit is deemed viable and
ria found in leeches. At our hospital, we are experi- successful, the patient enters extensive occupational
menting with adding the antibiotic ciprofloxicin to the therapy aimed at achieving maximal return of func-
solution in which the leeches live for 24 hours before tion. Depending on the method of bony fixation (ie,
they are applied to patients. The number of necessary rigid versus stainless steel surgical wires), mobiliza-
leeches depends on the seventy of the patient’s venous tion might start as early as the first week after digital
congestion. Leeches range in price but are approxi- replantation. The patients have regular follow-up
mately six dollars each. This expense usually is covered schedules with surgeons, initially making weekly
by the patient’s insurance company as a medication. visits and progressing to monthly visits. During this
time, patients also see hand therapists several times
LEECH APPLICATION each week. Patients often are out of work for six
Factors influencing leech application are related months after digital replantation. Approximately one
to the leech’s behavior. The leech must be “hungry” half of all patients will require some form of adjunc-
and must exhibit feeding behavior; that is, it must tive surgery (eg, tenolysis, capsulotomies) to deal

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with the postoperative complication of stiff fingers.


Approximately 90% of all digit replantations are
successful.** Jeanne J. Quinn, RN, BS, CNOR, is
an OR staff nurse specializing in
plastic and reconstructive and oral
CONCLUSION
maxillofacial surgery at the Univer-
Leech therapy can be an important adjunct to
sity of Pennsylvania Medical Center,
surgeons in the treatment of congested digital replan- Philadelphia.
tation. Perioperative nurses play a crucial role in
ensuring the success of this surgical procedure by
helping the patient meet the outcome goal of restored Marshall T. Parfington,MD, is an
digital function. A assistantprofessor of plastic surgery,
director of microsurgical replantation
and transplantation,aid director of
the microsurgical research laboratory
at the University of Pennsylvania
Mary Ann Golden, RN, BS, CNOR, Medical Center, Philadelphia.
is the service coordinatorfor plastics
and oral maxillofacial surgery at the The authors wish to thank David Low,MD, an assistant
University of Pennsylvania Medical professor of surgery, Division of Plastic Surgery, Univer-
Center, Philadelphia. sity of Pennsylvania School of Medicine, Philadelphia.

NOTES 201-203. 20. C Westlake, “Commitmentto


1. M M O’Hara, “Beauty and the 8. Foucher, Norris, “Distal and function: Microsurgicalflaps,” Plas-
beast: Nursing care of the patient very distal replantations,” 199-203. tic Surgical Nursing 3 (Fall 1991)
undergoing leech therapy,”Plastic 9. Ibid. 95-100.
Surgery Nursing 11 (Fall 1991) 101- 10. C Lewellyn, “Emergencycare 21. H J Buncke et al, “Monitor-
104. of the replant patient,” Critical Care ing,” in Microsurgeiy: Transplanta-
2. B R West, L S Nichter, D Nursing Quarterly 13 (June 1990) tion-Replantation:An Atlas-Text, ed
Halpem, “Leech therapy: When once 13-18. H J Buncke, (Philadelphia:Lea &
is not enough,”Blood Coagulation 11. Ibid. Febiger, 1991)715-720.
and Fibrinolysis 2 (February 1991) 12. L Gordon et al, “Partial nail 22. Ibid.
197-200. plate removal after digital replanta- 23. Pollard, “The patient with trau-
3. G Foucher, R W Norris, “Dis- tion as an alternative method of ma,”484-486.
tal and very distal replantations,” venous drainage,”Journal of Hand 24. W C Lineaweaver et al, “Clini-
British Journal of Plastic Surgery 45 Surgery 10 (May 1985) 360-363. cal leech use in a microsurgicalunit:
(April, 1992) 199-203. 13. J Baudet, “The use of leeches The San Francisco experience,”
4. O’Hara, “Beauty and the beast: in distal digital replantation,”Blood Blood Coagulation and Fibrinolysis
Nursing care of the patient undergo- Coagulation and Fibrinolysis 2 (Feb- 2 (February 1991) 189-192.
ing leech therapy,” 101-104. ruary 1991) 193-196. 25. F A Valauri, “The use of medi-
5. R W Dabb, J M Malone, L C 14. Foucher, Noms, “Distal and cinal leeches in microsurgery,”Blood
Leverett, “The use of medicinal very distal replantations,” 199-203. Coagulation and Fibrinolysis 2 (Feb-
leeches in the salvage of flaps with 15. Ibid. ruary 1991) 185-187.
venous congestion,”Annals of Plas- 16. Ibid. 26. P Cmiel, “Postoperativeman-
tic Surgery 29 (September 1992) 17. Baudet, “The use of leeches in agement of the replant patient: Moni-
250-256. distal digital replantation,” 193-196. toring, complications, and educa-
6. M D Wells et al, “The medical 18. B Pollard, “The patient with tion,” Critical Care Nursing Quai--
leech: An old treatment revisited,” trauma,” in Anesthesiology:A Con- terly 13 (June 1990)47-54.
Microsurgery 14 (1993) 183-186. cise Textbook, ed T J DeKomfeld 27. L S Kocent, S S Spinner,
7. W C Lineaweaver, (New York Medical Examination “Leech therapy: New procedure for
“Aeromonas hydrophilia infections Publishing Co, 1986) 484-486. an old treatment,”Pediatric Nursing
following clinical use of medicinal 19. Gordon et al, “Partial nail plate 18 (September/October1992) 481-
leeches: A review of published removal after digital replantation as 483.
cases,” Blood Coagulation and an alternativemethod of venous 28. H J Buncke et al, “Monitor-
Fibrinolysis 2 (February 1991) drainage,” 360-363. ing,” 715-720.

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