I had this discussion with one of the breast surgeons a few weeks ago. I don't know the research, but she said that lymphedema can happen pretty much at any time in the 4-5 years following dissection, but she does not worry about IV sticks assuming it's not going to be a large gauge or large volume infusion (RIC in the A/C used for 4 units of prbc etc) and that the IV is coming out in a day or two. She did not have a problem with placing 18 or smaller IV in the affected extremity assuming it's as distal as possible, i.e. not in A/C, upper extremity brachial, cephalic, basilic etc.
As far as the mechanism, I don't think it's the fluid anyone is worried about, but rather the risk of inflammation/infection/phlebitis precipitating lymphedema. Probably wouldn't be unreasonable to use chlorhex and sterile gloves if you have to stick an affected extremity.
Most of the data is retrospective, old, and very poor:
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3652571/
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Avoidance of needle sticks
This is perhaps the most common preventative measure for patients at risk for developing lymphedema and is based on the concept that these injures may lead to infection and hence development or exacerbation of lymphedema. Most hospitals recommend this even in patients who have undergone sentinel lymph node biopsy. Patients are often designated with armbands and other measures to avoid accidental or inadvertent blood draws/needle sticks. Patients and clinicians often go to great lengths to adhere to this recommendation by performing blood draws from foot veins or having central venous catheters placed.
The historical source of this recommendation probably dates back to Halstead who in 1921, hypothesised that post-surgical infection or infection was the underlying cause of swelling of the arm following breast cancer surgery
11. Unfortunately, the vast majority of evidence that opposes or supports this recommendation is of poor scientific quality (level 4 or 5). Most reports are small series and anecdotal observations. For example, in a retrospective study of 79 patients treated with breast cancer, Villasor’s level 3 study reported that 3 patients developed lymphedema immediately after venipuncture of the affected arm and based on this finding proposed that venipuncture of the affected arm should be avoided.
12. Similarly, Britton and Nelson in 1962 performed a level 4 retrospective study to identify etiological factors for 114 patients who developed lymphedema after radical mastectomy and reported that 53% of these patients had a history of recurrent cellulitis following either an insect bite, cat scratch, needle or thorn prick with a marked increase in swelling or pain in their arm
13. They concluded that any mode of bacterial entry could trigger development of cellulitis and lymphedema leading to the recommendation of avoiding venipuncture and meticulous skin care to avoid development or exacerbation of lymphedema. Interestingly, this is the only reference in the literature that we encountered reporting a potential link between needle sticks and infection and appears to be the only evidence for the underlying rationale of this recommendation. A level 5 study by Smith and colleagues reported that 10 patients referred to the lymphedema service over a 2 year period reported a direct correlation with venipuncture and the onset of new swelling in their arms
14. Similarly, in an unusual level 4 report, Brennan et al described a case of a 78 year old woman who developed lymphedema 30 years after a left radical mastectomy after performing needle sticks for blood monitoring for her newly diagnosed diabetes
15. Other studies have never been published but were rather only reported at scientific conventions. Foldi, et al cite Harlow and colleagues at the 18th convention of the International Society of Lymphology (ISL) 2001, in which they reported a significantly increased rate of lymphedema in a group of 252 patients after venipuncture. No details or other data were provided
1.
Clark, Sitzia and Harlow performed the only level 2 prospective observational study in 2004 examining the incidence and risk factors (including hospital skin puncture) for arm lymphedema in patients with breast cancer
16. They measured limb circumference pre-operatively and at regular time periods post-operatively in 188 women who had undergone treatment for breast cancer. The authors reported that 8/18 (44%) patients who had any needle stick developed lymphedema as compared with 31/170 (18%) patients who did not have venipuncture, concluding that skin puncture statistically significantly increased the risk of lymphedema
16. The authors, however, did not report the timing of lymphedema development in relation to venipuncture and did not evaluate the effect of potential confounding variables that may alter the rate of lymphedema. In addition, although the measurements were made prospectively, the analysis was retrospective and no “randomization” was done.
Other retrospective case series have suggested that venipuncture does not increase the risk of lymphedema development after lymphadenectomy. Cole reported no cases of lymphedema development in a level 4 retrospective audit of 14 patients who had “non-accidental skin puncturing” with a 2 month follow up of the at risk limb
17. Similarly, in their level 4 study, Winge et al analyzed the results of a questionnaire administered to 348 patients treated for breast cancer. Of the 311 respondents, 88 reported a history of intravenous procedures on the affected side but only 4 developed swelling as a complication in relation to venipuncture
18. This finding led the authors to conclude that intravenous procedures on ipsilateral arms pose a very low risk of complications such as lymphedema however they acknowledge that their sample size is small, and the study is retrospective, advocating a need for larger multi-centred studies."
