IV's after axillary nodes dissection

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Planktonmd

Planktonmd

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This issue is way overdue for discussion on this forum.
Here is the typical scenario:
A patient shows up for ambulatory minor surgery and they tell you that you can't use a certain upper extremity for IV access because they had a mastectomy and lymph nodes dissection on that side, and their "Doctor" told them to never have IV's started on that side.
You attempt to start an IV on the other side but you fail... you see great veins on the forbidden side, you know what their "Doctor" told them is mainly BS, but you don't want to be liable if they develop lymphedema for whatever reason... what would you do?
 
Seeing good veins speaks to well-drained interstitium and I'd have little concern about running a slow/low volume IV in such an arm. That said, sometimes you've got to treat the patient AND the system. So I'd lay out the proposed concerns of others and suggest why I think it's probably safe. If the patient has any misgivings, yeah...get the ultrasound out...

I often think of this diagram in such such situations, bearing in mind that at times research evidence is lacking or my experience is weak or patient is deferential...

16572-6d97c46ee83c877e0792404e87ea1849.jpg
 

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So, the patient is a bit "special" and says she does not want a foot IV because that hurts too much... you review the chart and realize that this minor surgery was cancelled last month by your partner because they could not get an IV at the exact spot she wanted... what's the plan now?
 
Yeah, I'd vote for a little bubble gum flavored sevoflurane, too. Again, assuming that I could not persuade her to let me drop a little catheter on the side of her node dissection.
 
I might not have to secure the airway at all, depends on the procedure and comorbidities.
 
EZ-IO?
Mask her down, get some nice vasodialation and try her desired spot. Saph or feet as plan B.
You can drop an LMA if you must to get access on high sevo. Just have a sux syringe around and a needle out just in case.
And ask your partner to get his act together. The patient can have some input in the plan and you can avoid the arm, but the inmates can't run the asylum. One of my partners is the king of setting us all up with his caving to every family whim and setting up unrealistic expectations for all future anesthetics. I hear it all the time, Dr. PainInTheAss let us do this, doesn't do that, etc. "Sorry, he's not here today and this is why we will do it this way..."
I have offered to cancel and reschedule with him if they like. Sometimes it's a little crazy.
 
Basically, you are asking if there is any actual proof that the morbidity is low with IVs after node dissection and this is all dogma...does anyone have an actual incidence of lymphedema in this setting? Telling the patient it is "5%" or something low in your scenario would sway most reasonable people in the preop area but I'm not certain of the actual data.
 
This patient gets the same treatment as anyone else. I'd talk about why it's probably no big deal to start an IV in the arm that had the node dissection in it, but if they are skittish I look somewhere else whether that's foot or EJ or central line. If she can't/won't let me start one of those, or if I'm technically unable, she isn't having surgery today. Sorry.

Not doing a mask induction and then trying to fish for an EJ or IJ that I couldn't get with her awake.

just my 2 cents, but this scenario isn't worth overly special treatment. I've placed awake CVPs electively on people in a similar situation when there was nothing else to use. It's quick and easy and I'm not putting in a big 9 FR cordis so it's not uncomfortable for the patient.
 
Someone mentioned that good veins on the surgical side is evidence of decent lymphatics. Could be, but I'm not sure about that.

I guess the two concerns with anodal patients would be obstructing venous drainage leading to extravasation and lymph edema, or giving large volumes of fluid into the veins, possibly leading to extravasation and edema.

It seems like a hand/wrist iv would be no problem, because there are lots of collaterals and you aren't really obstructing anything. I think if you took it easy on the volumes, it wouldn't be a problem. I can certainly see avoiding a larger more proximal vein like an AC.

All that being said, I will adhere with patient requests when possible for the reasons mentioned in other posts
 
Intraosseous. I'm dying for one of these cases so I can give it a try. Just as safe and probably easier in patients with poor access.
 
So... if the patient is 100% convinced that placing an IV on the side where she had her nodes dissected is not allowed should we still tell her that it's OK and do it?
What if she develops lymphedema later for whatever reason?
 
Mman said:
This patient gets the same treatment as anyone else. I'd talk about why it's probably no big deal to start an IV in the arm that had the node dissection in it, but if they are skittish I look somewhere else whether that's foot or EJ or central line. If she can't/won't let me start one of those, or if I'm technically unable, she isn't having surgery today. Sorry.

Not doing a mask induction and then trying to fish for an EJ or IJ that I couldn't get with her awake.

just my 2 cents, but this scenario isn't worth overly special treatment. I've placed awake CVPs electively on people in a similar situation when there was nothing else to use. It's quick and easy and I'm not putting in a big 9 FR cordis so it's not uncomfortable for the patient.
Click to expand...
Why is mask induction so bad in your opinion?
 
Pooh & Annie said:
It seems like a hand/wrist iv would be no problem, because there are lots of collaterals and you aren't really obstructing anything. I think if you took it easy on the volumes, it wouldn't be a problem. I can certainly see avoiding a larger more proximal vein like an AC.
Click to expand...

Help me understand the anatomy here. So if there're collaterals around the hand/wrist veins, that somehow bypasses poor drainage in the axilla?
 
Single lumen IJ ought to be easy enough, ultrasound or no.


What's the actual risk of using the arm? Vascular drainage should be normal, unless the axillary lymph node dissection chopped out some veins too. (Then again, maybe the reason the veins on the forbidden arm look so "great" is because they're not quite normal downstream.) Lymphatic drainage, not so normal, but that's only going to be an issue if the IV goes bad and you get extravasation. I don't see any real risk for a carefully monitored IV for an outpatient procedure and would use the affected arm ... IF the patient was on board with it. Usually it's the patient who's the most freaked out about the arm. I wouldn't try to talk her into it. Again, easy enough to put a long single lumen catheter into the IJ.
 
the veins should be fine, especially if you go distally and avoid caustic compounds. if anything they would be harder to see due to lymphedema.

happy to place an IV anywhere else to get a patient to sleep for ambulatory surgery followed by rescue IV in neck or groin if needed
 
cchoukal said:
Help me understand the anatomy here. So if there're collaterals around the hand/wrist veins, that somehow bypasses poor drainage in the axilla?
Click to expand...

the problem is not poor axillary drainage, per se, as long as there is venous drainage, since the axillary drainage you are worried about is lymphatic - shouldnt be a problem as long as you arent creating a lot of tissue edema. the assumption is that if you blow a vein in the hand, you have others to facilitate drainage from that area...if you blow the AC, you have a much greater risk of distal complications
 
Another similar scenario I see a lot is pt scheduled for arm/shoulder surgery on the side contralateral to the lymph node dissection. So you can't put an IV in either arm...
 
Idiopathic said:
the problem is not poor axillary drainage, per se, as long as there is venous drainage, since the axillary drainage you are worried about is lymphatic - shouldnt be a problem as long as you arent creating a lot of tissue edema. the assumption is that if you blow a vein in the hand, you have others to facilitate drainage from that area...if you blow the AC, you have a much greater risk of distal complications
Click to expand...
This. And, an IV WILL cause an increase in venous pressures distal to it ( larger bore more so, obviously), potentially leading to extravasation. In the hand that back pressure will be next to nothing because of collaterals, in the AC or somewhere proximal it might be a bigger problem.

This is all just theoretical on my part. I don't put IVs in the arm if the patient was told not to have them there.
 
I would try very hard not to put an iv on the side with the node dissection. If I cannot get anything, I would have a long discussion with the patient about options and risks. Then, let the patient decide. Maybe she wants to risk lymphedema, or maybe not.

I don't think not having a ultrasound is a good excuse. Maybe the patient should be done at a facility with an ultrasound.
 
Planktonmd said:
Why is mask induction so bad in your opinion?
Click to expand...

Never said it's bad in and of itself. But what's wrong with starting an IV on a patient preop? That's what I'm doing. If it can't be easily done, I'm certainly not mask inducing an adult just to start a difficult IV after they are asleep for an elective procedure. Asking for too much badness and it would be indefensible if you got a bad outcome.
 
I'm a general surgeon.


There is absolutely zero contra-indication to putting in IV in a patient who had a ax dissection dissection who doesn't have sign isn't edema.

You will find the vast majority of patients don't even have a hx if a dissection but rather just a sentient node..... Which is absolutely completely never a contra-indication.

U can also use a bp cuff on that arm.
 
Mman said:
Never said it's bad in and of itself. But what's wrong with starting an IV on a patient preop? That's what I'm doing. If it can't be easily done, I'm certainly not mask inducing an adult just to start a difficult IV after they are asleep for an elective procedure. Asking for too much badness and it would be indefensible if you got a bad outcome.
Click to expand...
I'm not so sure a mask induction in an adult is so indefensible. If there are no contraindications, there are no contraindications. Peds anesthesiologists do it every day on almost every patient. Even 18 and 21 year olds if they ask for it. And your reason for doing it would be legitimate, a failed IV attempt in a limited access patient for volatile induced vasodialation. I'll testify it meets the standard of care as long as she's not a full stomach or symptomatic GERD patient.
 
I see veins in an extremity that has had a node dissection and it is my only option for veinous access prior to outpatient surgery? I will place an IV wherever I can. Doing so does not dictate that I give an extremity-compromising amount of volume through it, pretty much regardless of the case that is rightly booked as being "outpatient."

If there's question as to whether the case should be booked in the ambulatory vs. inpatient setting, well then I think that this is where you can make a case for being conservative. In this situation, my own opinion is that the patient should be taken care of in a hospital where a central line can be inserted and removed, easily.
 
IlDestriero said:
I'm not so sure a mask induction in an adult is so indefensible. If there are no contraindications, there are no contraindications. Peds anesthesiologists do it every day on almost every patient. Even 18 and 21 year olds if they ask for it. And your reason for doing it would be legitimate, a failed IV attempt in a limited access patient for volatile induced vasodialation. I'll testify it meets the standard of care as long as she's not a full stomach or symptomatic GERD patient.
Click to expand...


Failed IV access? If I'm unable to obtain routine IV access on a normal adult, including potentially an awake central line, I'm not mask inducing the patient for an elective procedure and then struggling to get an IV while she is having laryngospasm. Peds anesthesiologists (and me) do it every day in kids because it is easy and safe and is considered within the standard of care. Not sure who does it in 18 or 21 year olds if they ask for it. I certainly don't. I start IVs in 8 year olds >90% of the time in preop holding.

If you took a survey of board certified anesthesiologists and asked them how many would do a mask induction with no IV in a healthy adult for an elective procedure because the patient didn't want an IV, I doubt > 10% would go for it.
 
Seems like the risk of laryngospasm is less in adults, so it would seem that inhalation induction could be seen as safer in adults than in children. Assuming a reassuring airway that appears maskable. I'd be more worried about fat adults and difficult to ventilate adults. But even they respond well to an LMA almost all the time. That being said, if I don't have an ultrasound and I can't see any veins anywhere, I wouldn't gas them
 
Oggg said:
Seems like the risk of laryngospasm is less in adults, so it would seem that inhalation induction could be seen as safer in adults than in children. Assuming a reassuring airway that appears maskable. I'd be more worried about fat adults and difficult to ventilate adults. But even they respond well to an LMA almost all the time. That being said, if I don't have an ultrasound and I can't see any veins anywhere, I wouldn't gas them
Click to expand...

yeah certainly this is key. if they just freak out with the thought of needles/IVs thats one thing, but if your presumption is that you cant find one, Id be much more hesitant to go to sleep unless you are planning on sticking the neck, in which case this will be extremely difficult while masking a patient, you may commit yourself to a groin line. certainly you could cancel a case because of inability to get access, if you have no ultrasound, but i would imagine there is a vein somewhere
 
Mman said:
If you took a survey of board certified anesthesiologists and asked them how many would do a mask induction with no IV in a healthy adult for an elective procedure because the patient didn't want an IV, I doubt > 10% would go for it.
Click to expand...

even if the plan is to put one in as soon as they are asleep? ive done this on a few occasions and i think with the right patient its not the worst idea. if you think the mental health and well-being of the patient could be compromised by placing a preop IV, or the patient refuses, what do you do then?
 
I agree that masking someone down just so you can start digging for an IV with no promising target is a bad idea. If your just doing it for pt "comfort" reasons and they have nice veins then I see no problem with it. Although genereally for the "I'm afraid of needles crowd" a full mask induction is overkill/unnecessary. 60-70% Nitrous is all you need and they won't even feel it.
 
One alternative which I use in the trauma bay and many ER docs use all the time is an intra-Osseous line.

There is a lot of mis-conception about these lines from people who have not been trained or used them.

They do not hurt going in any more than an 18 g... And in my opinion even less because it's such a quick process. Try you tubing it and u will see.

Infusing medications is what CAN hurt but if u adequately lido them it can be easily over come.

I use them as an intensivist when patients on the floor need access in order to get them intubated/stabilized and transferred to icu where i can then put a central line in controlled conditions. In the ER I use them for patients who are agitated, moving and often also a difficult stick (iv drug abuser type). And In trauma we use them at first when peripheral not working and central lines are being prepared.

The more and more I use them I realize just how great they are and my
Threshold lowers all the time.


The only bad thing about them is they are a bit expensive.


And I'm talking about the ones with a drill not the ones with Manuel insertion.
 
I've never used I/O in a non-crumping patient. In the presented scenario, who would use local anesthetic vs. go straight to the I/O?
 
Idiopathic said:
even if the plan is to put one in as soon as they are asleep? ive done this on a few occasions and i think with the right patient its not the worst idea. if you think the mental health and well-being of the patient could be compromised by placing a preop IV, or the patient refuses, what do you do then?
Click to expand...

Compromising the mental health and well being of the patient? Really? I talk to them. You must be describing some scenario that I've never encountered.
 
Occasionally we have pts who need the surgery, but are so anxious that after being stuck a few times, they demand to be asleep for the next stick, or else they are canceling.
 
Mman said:
Compromising the mental health and well being of the patient? Really? I talk to them. You must be describing some scenario that I've never encountered.
Click to expand...

im just saying, its a reasonable alternative in some situations. im not sure its indefensible.
 
I have had this a few times. Usually can talk them into an iv on the dissected arm and I tell them we will give them minimal fluid and if they are worried keep it elevated when they go home. I will also do feet iv's or mask inductions. I have once had a very stubborn lady who had horrible diabetic feet with no easy place to put it and the same day nurse had already blown a few spots on the good arm. She refused an iv on the dissected side but we had no great options and she didn't want the mask. We bargained to a hep lock on the dissected side and just drugs to put to sleep and intubated and then put something some where else after she was asleep. Blaz
 
europeman said:
I'm a general surgeon.


There is absolutely zero contra-indication to putting in IV in a patient who had a ax dissection dissection who doesn't have sign isn't edema.

You will find the vast majority of patients don't even have a hx if a dissection but rather just a sentient node..... Which is absolutely completely never a contra-indication.

U can also use a bp cuff on that arm.
Click to expand...
I agree with you...
But unfortunately these patients usually come to us absolutely convinced that starting an IV on that side is going to cause lymphedema and a life of misery.
This is what the surgeon who did their node dissection told them and many of them tend to believe their surgeon's advice not the words of an anesthesiologist they just met.
Many of them are also a little bit nervous, irrational and occasionally crazy.
So the challenge is rather a psychological than anatomical one.
 
By the way, I do mask inductions on adults for multiple reasons and one of these reasons would be patients who are too anxious and upset about the IV stick because of previous bad experience.
I wouldn't do it on a morbidly obese patient with documented difficult intubation and bowel obstruction but I can still find patients who can be decent candidates for this approach.
 
Planktonmd said:
By the way, I do mask inductions on adults for multiple reasons and one of these reasons would be patients who are too anxious and upset about the IV stick because of previous bad experience.
I wouldn't do it on a morbidly obese patient with documented difficult intubation and bowel obstruction but I can still find patients who can be decent candidates for this approach.
Click to expand...

I simply talk to those patients and make it a better experience this time. I'm 0 for my career not having a satisfied patient when it is all said and done and I haven't set up their expectation for having mask inductions for future surgeries which could be contraindicated and then they really have a breakdown.
 
Mman said:
I simply talk to those patients and make it a better experience this time. I'm 0 for my career not having a satisfied patient when it is all said and done and I haven't set up their expectation for having mask inductions for future surgeries which could be contraindicated and then they really have a breakdown.
Click to expand...
Sometimes talking to people is not as powerful as Sevoflurane!
 
I think we should start calling the surgeon that did the lymph node dissection to have them tell the patient its ok for the IV. Maybe if they have to deal with a barrage of calls they will stop telling the patients its an absolute contraindication. Recently I had this issue, told pt I was happy to place foot iv, and they flipped! Told me their surgeon had already given their blessing for the arm in question to have an IV.

A central line does carry risks, I know its small especially in experienced hands... but all the same, I have seen people die from incorrectly placed lines. I dont think the patient has the right to demand something that has a higher risk level.
 
Mman said:
Failed IV access? If I'm unable to obtain routine IV access on a normal adult, including potentially an awake central line, I'm not mask inducing the patient for an elective procedure and then struggling to get an IV while she is having laryngospasm. Peds anesthesiologists (and me) do it every day in kids because it is easy and safe and is considered within the standard of care. Not sure who does it in 18 or 21 year olds if they ask for it. I certainly don't. I start IVs in 8 year olds >90% of the time in preop holding.

If you took a survey of board certified anesthesiologists and asked them how many would do a mask induction with no IV in a healthy adult for an elective procedure because the patient didn't want an IV, I doubt > 10% would go for it.
Click to expand...

I mask older kids 8+ if they are afraid of ivs (fellowship trained pedi guy) it's really no big deal. Ivs can be very traumatic for certain kids why risk the post op cognitive dysfunction... Btw the literature on this is tremendous most of us anesthesia people don't think of it because we never hear about it. My gf in fp/peds deals with it a lot ! Granted do what u are comfortable but masking this patient is by ALL means defensible...
 
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