s/p mastectomy and IV access

[badasshairday]

So I had an RN freak out about establishing IV access and getting lab draws off of a patient who had a R breast mastectomy over 20 years ago. The patient also has a dialysis graft on the left arm. I understand avoiding the left side since the graft is so valuable we would never want to risk infection ect. But why are nurses so worried about the upper extremity on the same side of the mastectomy? I mean I get it if the patient has lymphedema after the surgery, but this patient had surgery over 20 years ago without any signs of lymphedema. RN tale or what?

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[ajimd]

A lot of what RN's do today is based on hospital guidelines and protocol...whether it's the right thing to do or not. Truth be told, if you do have someone with a h/o lymphadenectomy, the last thing you want is someone rocking the boat by trying to stick the arm prone to lymphedema/VTE...etc. If they would get the stick at the first pass, then great, but unfortunately thats usually not how it goes. No need to risk creating a very morbid condition for the patient when there are a plethora og places you can draw blood from (EJ, fem stick)

 

[blue2000]

Also, lymphadema can occur at any time after a mastectomy; it's not a time dependent phenomena. 20 years ago, you can be assured that the patient had a full axillary lymph node dissection rather than a sentinel node (while there is an increased risk of lymphedema in patients with SLN, it is not nearly as common compared with full ALND) and that also is a risk factor for lymphedema. I would definitely not stick the side with the graft, but there is a risk on the other side as well.

 

[badasshairday]

Thanks, I did not know that. There isn't too much about it when I searched for info. Most of the things I found were protocols that stated do not do lab draws or iv insertions on the upper extremity that is on the same side as the mastectomy.

 

[45408]

You could always to an IV in the leg or neck, but it would be much better to put an arm IV on the mastectomy side than the dialysis side. Losing your fistula would be much worse.

 

[danzman]

I have always wondered why we don't just always do an EJ on these kinds of people. Seems to be a simple fix.

http://www.dagwfu.com/files/ASDIN.pdf

In pts with chronic kidney dz, use hand, then IJ, or EJ. No SC or PICC. If you don't want to mess with possible lymphadema issues, just do an EJ.

 

[joeDO2]

Hmmm interesting thoughts with use of EJ. I suppose it would be a decent option on these types of patients. It seems to be discouraged in some settings due to possible complications that are not present with peripheral access....i.e. air embolism, hematoma, etc when done by inexperienced practitioners with improper technique. Also, I have been told to never use them for certain fluids/meds, for example it should not be used for D50 admin due to risk of tissue necrosis if extravasation occurs.

 

[Winged Scapula]

Almost all of the studies on lymphedema are incredibly weak, based on inaccurate or conflicting measures of arm circumference. The RN was freaking out because her textbook most likely references a nearly 70 year old study, with 6 patients, that showed an increased risk of LE in the first 2 years after a RADICAL mastectomy with IV starts and BP measures.

They perpetuate this myth that LE is a significant risk in modern patients (poll your nurses and you will also find that they assume the same risk with SLNB patients and patients with mastectomy WITHOUT axillary staging - they simply do not know what they don't know, or what the risks are).

However, it is true that the risk doesn't go away after 2 years and it can occur 20 years out; its just pretty darn low. You can assume that a patient operated on 20 years ago had a MRM with a larger number of nodes removed than in modern hands.

My tactic is to educate patient and nursing staff about the *reasonable* risks and if the patient has other access, to use it. Recent study presented at ASBS (Amer Soc of Breast Surgeons) showed that 75% of patients operated on for breast cancer report concern over LE, modern day rates with SLNB and AxND are single digits. So the fear and ignorance far outweighs the risk, but why take a chance *if* you have other reasonable access points.

Can't say I've ever had an EJ placed in my bilateral patients. Seems like a lot of work and possible complications for a patient who's going home in 24 hours or less.

 

[danzman]

Almost all of the studies on lymphedema are incredibly weak, based on inaccurate or conflicting measures of arm circumference. The RN was freaking out because her textbook most likely references a nearly 70 year old study, with 6 patients, that showed an increased risk of LE in the first 2 years after a RADICAL mastectomy with IV starts and BP measures.

They perpetuate this myth that LE is a significant risk in modern patients (poll your nurses and you will also find that they assume the same risk with SLNB patients and patients with mastectomy WITHOUT axillary staging - they simply do not know what they don't know, or what the risks are).

However, it is true that the risk doesn't go away after 2 years and it can occur 20 years out; its just pretty darn low. You can assume that a patient operated on 20 years ago had a MRM with a larger number of nodes removed than in modern hands.

My tactic is to educate patient and nursing staff about the *reasonable* risks and if the patient has other access, to use it. Recent study presented at ASBS (Amer Soc of Breast Surgeons) showed that 75% of patients operated on for breast cancer report concern over LE, modern day rates with SLNB and AxND are single digits. So the fear and ignorance far outweighs the risk, but why take a chance *if* you have other reasonable access points.

Can't say I've ever had an EJ placed in my bilateral patients. Seems like a lot of work and possible complications for a patient who's going home in 24 hours or less.

Thats interesting. I didn't realize the origins of this concept. So then do you just always use a peripheral? What about a pt who actually has some degree of current LE? I have seen a few women that had mild LE SP mastectomy on one side. They wouldn't let anyone even look at the arm for fear of making it worse. In those it was always possible to use the other arm, but I always wondered how it would go if you couldn't (fistula etc').

 

[Winged Scapula]

Thats interesting. I didn't realize the origins of this concept.

There are certainly more modern studies available but again, there is little standardization on measurement of arm circumference and many of them use patient self-report (which is not surprisingly inaccurate especially here given the level of patient paranoia about LE). it is something that warrants more and better work; its just so non-sexy that its not a very popular topic.

So then do you just always use a peripheral? What about a pt who actually has some degree of current LE? I have seen a few women that had mild LE SP mastectomy on one side. They wouldn't let anyone even look at the arm for fear of making it worse. In those it was always possible to use the other arm, but I always wondered how it would go if you couldn't (fistula etc').

Yes, we use a peripheral. I try and have it be a "one stick" placement and DC it ASAP (>90% of my mastectomy patients are home within 24 hours and are eating within 6).

Fortunately, I haven't had to face that situation (i.e., couldn't use the other side) very often and I rarely see patients with significant LE. But you're right - patients will freak out because they've been taught for years by nurses, Google, LE specialists to avoid IVs on that side. In that case, we generally place a foot IV and discontinue it early which makes me sort of uncomfortable. I typically have a "rule" that patients in the hospital have to have an IV but I suppose in the rare case that you present (patient with significant contralateral LE and a fistula on the other side), an EJ or other access would be reasonable.

 

[danzman]

There are certainly more modern studies available but again, there is little standardization on measurement of arm circumference and many of them use patient self-report (which is not surprisingly inaccurate especially here given the level of patient paranoia about LE). it is something that warrants more and better work; its just so non-sexy that its not a very popular topic.



Yes, we use a peripheral. I try and have it be a "one stick" placement and DC it ASAP (>90% of my mastectomy patients are home within 24 hours and are eating within 6).

Fortunately, I haven't had to face that situation (i.e., couldn't use the other side) very often and I rarely see patients with significant LE. But you're right - patients will freak out because they've been taught for years by nurses, Google, LE specialists to avoid IVs on that side. In that case, we generally place a foot IV and discontinue it early which makes me sort of uncomfortable. I typically have a "rule" that patients in the hospital have to have an IV but I suppose in the rare case that you present (patient with significant contralateral LE and a fistula on the other side), an EJ or other access would be reasonable.

Thanks for the info!

 

[45408]

What about blood pressures and lab draws? Those have to be even less "risky" than an IV placement.


I have seen an AV graft get virtually destroyed from a BP cuff. It had been recently placed, and I don't remember the exact complication, but someone threw it on the guy's arm in urgent care and did serious damage.

 

[Hamhock]

What's the supposed mechanism for LE from an IV on the side of an old mastectomy?

HH

 

[TrustMe]

As a recent anesthesiology grad I got similar scenarios very often. RN puts bracelet on pt. saying no blood draws/IV's/BP's and announces it to everyone in the pre-op area. Before I even attempt an IV I always ask when they had their mastectomy and if they had ALND. RN's rarely ask follow-up questions. Like Winged Scapula said, if they didn't have LND, problem solved. If they had it recently, they probably just had SLND and risk of LE is less. My next question is if they have ever had a DVT. If not, then feet are an option. If they have had a DVT, then I avoid the feet/legs. The ESRD/mastectomy pt's are challenging. I use the mastectomy side if no severe LE. If not possible, going distal to the AVF/AVG is an option. Not ideal, but possible. If you put the tourniquet distal to the fistula/graft you should be okay as this will not affect the arterial (inflow) flow to the graft. Access in these pt's is often a nightmare as they have likely had many/many/many EJ's/IJ's/femoral lines/etc. This is one of the more frustrating scenarios that I encounter. Educate yourself on the literature and protocols so that you can then educate the pt. and RN if needed. I still don't fully understand why people think that taking the BP will affect their arm, though.