Lymphedema and Vascular Access Overcoming the Myths Sheryl McDiarmid, RN, BSCN, MEd, MBA, AOCN®, ACNP, CVAA(c),CRNI(c) CVAA Vancouver 2016 Financial Disclosures 1. Disclosure of Relevant Financial Relationships None 2. Disclosure of Off-Label and/or investigative Uses I will not discuss off label use and/or investigational use in my presentation. CVAA Vancouver 2016 Learning Objectives: This session will: Review anatomy and physiology of the lymphatic system Identify risk factors for secondary lymphedema Describe the implications for vascular access clinicians Discuss strategies for overcoming the myths to ensure patients and clinicians make well informed decisions related to vascular access and lymphedema CVAA Vancouver 2016 Why is it so important? 25,000 women are diagnosed each year with cancer 5 year survival with stage III 72% 15% of women with metastatic breast cancer survive more than 5 years Median age at diagnosis is 61 years Breast cancer incidence continues to rise while mortality rates continue to fall Patients surviving breast cancer develop other health problems that require vascular access CVAA Vancouver 2016 The Lymphatic System A network of tissues and organs • Lymph vessels • One way and open ended • Thin walled, some valved • Superficial and deep • Lymph fluid • Protein rich fluid • 20-30 Litres/day produced • Forced through vessels by body movements • Lymph nodes • > 600 throughout the body • Filter harmful substances Anatomy of the Lymphatic and Immune Systems by OpenStax CVAA Vancouver 2016 The Lymphatic System Functions • Preservation of fluid balance • Filters and collects lymph and large molecules in the interstitial space that come from the intravascular space • Intestinal lymphatic vessels absorb lipids from the intestinal tract • Host defense • Immune surveillance • Transports antigens CVAA Vancouver 2016 Lymphatic Capillaries Interstitial fluid enters the lymphatic system and becomes “lymph fluid” Lymph then travels through multiple lymphatic channels and nodes before returning to the venous system by the thoracic duct. The entry of fluid and other materials into the interstitial space is balanced by outflow of the lymphatic fluid Anatomy of the Lymphatic and Immune Systems by OpenStax CVAA Vancouver 2016 Lymphedema Swelling in a body part due to excess accumulation of protein rich fluid in the interstitial spaces. Starling’s law "... there must be a balance between the hydrostatic pressure of the blood in the capillaries and the osmotic attraction of the blood for the surrounding fluids. “ Starling, E.H. On the adsorption of fluid from interstitial spaces. J Physiol. London 19:312-326, 1896. CVAA Vancouver 2016 No universal definition of lymphedema 10% or greater change in limb volume Greater than 1 cm to 2 cm change from baseline Greater than 2 cm change from unaffected limb 2 cm increase in 2 consecutive anatomic sites Greater than 200 mL of volume increase ACOSOG : 2cm or greater increase over the baseline or greater than 10% increase in circumference of the ipsilateral arm at 10 cm proximal and distal to the lateral epicondyles. Subjective reports of heaviness, pain CVAA Vancouver 2016 Differential Diagnosis Edema Deep Vein Thrombosis Chronic Venous Insufficiency Infection Malignancy CVAA Vancouver 2016 Pathophysiology of Lymphedema A transport system breakdown with edema and protein A result of damage or malformation of the lymph system CVAA Vancouver 2016 Forms of Lymphedema Primary Impaired development of the lymph system Occurs most often in lower extremities May be present at birth or may develop later in life Secondary Often insidious A result of damage to the lymph system CVAA Vancouver 2016 Secondary Lymphedema CVAA Vancouver 2016 Lower-Limb Lymphedema Gynecological cancers (20%) Vulvar cancer (36%) Ovarian cancer (5%) Melanoma (16%) Genitourinary cancer (10%) CVAA Vancouver 2016 Stages of Lymphedema Stage 1 (latency) Subclinical Stage 2 (Spontaneous reversible) Mild – soft pitting edema that elevation resolves Stage 3 (Spontaneous irreversible) Moderate – fibrosis that reduces the ability of the skin to indent with pressure Stage 4 (Elephantiasis) Severe – fibrosis with hypertrophic skin changes, massive limb size changes possible Stage 5 Progression to malignant lymphangio-sarcoma CVAA Vancouver 2016 Epidemiology of Lymphedema in Patients with Breast Cancer 15-20% of breast cancer survivors are at a clinical risk of lymphedema 80-85% will remain free of lymphedema occurrence Can occur within days to up to 30 years after treatment for breast cancer Average time to onset is 14.4 months after treatment completion 70% experience onset within 2 years of surgery,90% within 3years 1% per year onwards CVAA Vancouver 2016 Breast Cancer Stage at Diagnosis 61% of breast cancer cases are diagnosed while the cancer is still confined to the primary site- localized. (Stage I and II) 31% are diagnosed after the cancer has spread to regional lymph nodes or directly beyond the primary site - regional. (Stage III) 6% are diagnosed after the cancer has already metastasized - metastatic (Stage IV) Staging information is unknown for 2% remaining CVAA Vancouver 2016 Risk Factors Associated with the Development of Breast Cancer Associated Lymphedema Axillary lymph node dissection > 10 nodes removed Sentinel node excision between 5 & 17% Obesity – BMI greater than 30 at time of diagnosis – 3.6% more likely to develop lymphedema Radiotherapy Scarring of the left or right subclavian lymphatic ducts by either surgery or radiation Delayed wound healing (cellulitis) CVAA Vancouver 2016 Sentinel Lymph Node Dissection When is it indicated? When is it not indicated? Ductal Carcinoma in Situ (DCIS) When the cancer is > 5cm or with mastectomy locally advanced In women who have previously Inflammatory breast cancer had breast cancer surgery or DCIS treated with lumpectomy axillary node surgery The woman is pregnant In women who have been treated before with systemic treatment CVAA Vancouver 2016 Lymph Node Dissection • In both types lymph nodes are removed Axillary Lymph Node • Axillary dissection Dissection removes more • Extensive tissue damage can occur with axillary dissection • Since 1998 the use of SLB has increased from 27% to 66% • No lymph node dissection is indicated in de novo stage IV breast cancer CVAA Vancouver 2016 Staging Breast Cancer Do patients: Know the extent of their lymph node dissections? Understand the long term risks related to axillary lymph node biopsy? Recognize that sentinel lymph node biopsy is evolving in selected clinical settings? Know that surgeon expertise is an important factor in staging outcomes? CVAA Vancouver 2016 Impact of Lymphedema on Patients Altered sensation in the limb Loss of body confidence, decreased physical activity, fatigue Psychological distress, frustration, depression, and anxiety are reported time and time again using well established and validated tools Overall reduction in quality of life CVAA Vancouver 2016 Preventing Lymphedema CVAA Vancouver 2016 Prevention of Lymphedema What is the recommendation to not establish vascular access on the “affected side” based on? In 1992 a women noticed the onset of lymphedema 30 years after breast cancer surgery and 10 days after she commenced finger prick testing to monitor her diabetes…… Another case of a sewing machine needle puncture and subsequent lymphedema…. Single case of lymphedema post vaccination on surgical side CVAA Vancouver 2016 Preventing Lymphedema by Avoiding Venipuncture What is the Issue: If a foreign object (needle) is placed in the arm does it cause an immune response and put the lymphatic system under more stress? Infection? Sterile vascular access devices are inserted using aseptic technique and closely monitored for phlebitis. Maki 2006 reports the infection rate with peripheral intravenous catheters was 0.5 per 1000 catheter days Is it the tourniquet? CVAA Vancouver 2016 National Lymphedema Network People at risk for developing lymphedema should consider taking the following actions and precautions: If required to have venipuncture inform the phlebotomist of your lymphedema risk and use a not-at-risk limb if possible. If not possible, inform the phlebotomist of your lymphedema risk condition and ask for the most experienced phlebotomist. Do not allow multiple or traumatic searches for veins, which can increase tissue edema. Cites Cole, T. Risks and benefits of needle use in patients after axillary surgery. BrJNurs. 2006;15(18):969-979 CVAA Vancouver 2016 What Does T. Cole have to Say? This article discusses the current evidence available on the subject of non-accidental skin puncture (NASP) relating to the patient at risk of lymphedema and provides guidelines for any professionals conducting such procedures for patients with a history of cancer. The results from a small audit of the guidelines are cited and they reveal that out of 14 patients who underwent NASP procedures in the at risk arm, no patients reported swelling to that limb within a month of these procedures. CVAA Vancouver 2016 Cole continues In light of little methodological sound evidence any research or case reports that have been published can be useful to guide practice. Clark et al (2005) in the only prospective study available concluded: Skin puncture (44% versus 18% for those who had none), mastectomy, and BMI > 26 significantly increased the risk of lymphedema. Other features previously postulated as risk factors (surgery on dominant side, age, axillary node status, number of axillary nodes removed, radiotherapy) were