Standard limb precautions — such as avoiding blood pressure measurements and venipuncture in the ipsilateral arm — may not decrease the incidence of lymphedema in patients who undergo breast cancer surgery with axillary lymph node dissection (ALND) or sentinel lymph node biopsy (SLNB), a researcher reported.
Those broad precautions are being enforced at many institutions despite a lack of high-level evidence supporting these restrictions, stated Julie Ziemann, MS, APRN-CNP, AOCNP, of The Ohio State University James Cancer Hospital and Solove Research Institute in Columbus.
However, Ziemann reported in an e-poster presentation at the Oncology Nursing Society virtual meeting that measuring blood pressure (BP), venipuncture, and vascular access in the ipsilateral arm is likely safe for patients without lymphedema and without any kind of arm injury such as cellulitis or broken skin.
Most institutions will enforce limb restrictions, including measuring BP and venipuncture in the ipsilateral arm, for all patients who have undergone breast cancer surgery, regardless of the type or timing of surgery, they noted.
However, there is a lack of scientific evidence regarding risk reduction practices. For example, the National Lymphedema Network in its position statement on risk reduction practices noted that there is little in the way of evidence-based literature regarding many of the practices listed in its statement, and that many are “based on the knowledge of pathophysiology and decades of clinical experience by experts in the field.”
In addition, Ziemann’s team suggested that adhering to these broad restrictions “can result in delay of care, invasive procedures to establish access, increased risk of infection and VTE [venous thromboembolism], increased healthcare spending, and increased inconvenience to patients.”
The researchers asked how observing limb precautions versus not observing them affected the development of lymphedema. Based on six relevant research studies, as well as clinical practice guidelines from professional organizations, they concluded that “there is limited evidence to support lymphedema precautions for patients after mastectomy” with ALND or SLNB.
They further noted that because of the lack of high-quality evidence, more research is needed to determine whether removing restrictions is safe for patients.
“We do not recommend broad limb precautions for all patients after breast cancer removal surgery with ALND or SLNB,” the authors wrote. “We recommend that all patients who have undergone breast cancer removal surgery or SLNB followed by radiation be evaluated individually to determine whether standard limb precautions should be followed.”
With these findings in mind, a task force was formed at their institution to update limb precaution guidelines. These updated guidelines recommend that, if possible, IV access should be pursued in the unaffected arm first. If access can’t be established in the unaffected arm, the guidelines suggest that standard limb precautions should be followed in patients with:
- Known lymphedema
- Sustained chronic or unilateral swelling
- A hemodialysis fistula
- Recent tissue harvest or tissue graft
- Recent acute injury, fracture, trauma, or burns
- Flaccidity or decreased sensation in the ipsilateral arm
- Known thrombus or superior vena cava syndrome on the same side of the chest as the affected arm
The guidelines also recommend following standard limb precautions in patients who have undergone axillary dissection with axillary radiation, or have active infection, a diagnosis of current deep venous clot, or whose limb is being preserved for hemodialysis access.
“In patients who don’t meet these criteria we have determined it would be safe to establish access in the ipsilateral arm depending on patient preference,” Ziemann and colleagues concluded. “Individual patient preferences and patient condition, as well as provider recommendations, should always dictate clinical practice. Continued research on lymphedema precautions and continued research in the field of lymphedema, including new treatment options, will continue to guide the way as we determine whether lymphedema precautions after breast cancer removal surgery are evidence-based.”