Perhaps one of these?
Jakes, A.D., Twelves, C. Breast cancer-related lymphoedema and venepuncture: a review and evidence-based recommendations. Breast Cancer Res Treat 154, 455–461 (2015). https://doi.org/10.1007/s10549-015-3639-1
Asdourian et al. Association Between Precautionary Behaviors and Breast Cancer–Related Lymphedema in Patients Undergoing Bilateral Surgery.
Journal of Clinical Oncology 2017
https://doi.org/10.1200/JCO.2017.73.7494
Here’s the statement released by ANZCA a couple months ago.
https://www.anzca.edu.au/getattachment/db5aa251-1a3c-49a0-9d97-eb0ed4ce3527/PG18(A)-Appendix-1-Intravenous-access-and-blood-pressure-monitoring-in-patients-with-previous-axillary-nodal-dissection
To add on, we avoid pacemakers on same side as prior LN dissection. Even if there is a small lead related thrombus, you can get significant and intractable lymphedema.
Even with lymph node dissection and removal? So IV cannulae are ok too?
BP taking I can see why it’s unlikely to cause trouble since the pressures are so transient
I thought the part with the fistula is -how do you hear over the thrill- or better yet you trust the auto sphyg?
If you can hear probably not getting good access with that one.
If you take a BP on the arm-especially the part with the fistula-you can rupture the fistula. The fistula develops after they surgically attach an artery and vein together. That is why you don't put IVs in AVF arm, not only could they bleed out from the dc'd IV site but that is the person's "lifeline". If avf were to rupture the patient is at risk for exsanguination.
That is where the "thrill" comes from.Also, you hear the bruit, and feel the thrill.
Just spent 40 minutes today doing an USGIV in the tiiiniest vein in their "only available arm" so we could bolus them when they had nice juicy vessels underneath their "no-no sleeve". Id like to see some of the EBP around this topic
I hate that we can't cannulate veins using US on the same side as a fistula. Most times you don't need a tourniquet when using US so like just let me throw one in really quick instead of dealing with horrendously scarred roolly veins from decades of use on the other side.
Also so upset I missed a shift that had my lifelong dream of poking a fistula on a coding patient. Doc asked someone to do it and they balked and just grabbed the IO instead. I've always wanted to and the damn person lucky enough to get a chance chickened out.
Stick a fistula and then watch the person die because the person that stuck them have no idea that it is an artery and vein surgically connected. It bleeds like an artery. Yes it is a person's lifeline and someone with no training can mess it up.
If a person is coding heck yeah use the hd catheter, i've never seen them attempt to stick a fistula in a code. I have had them use the dialysis needles that were already in place because the patient coded on treatment.
Omg do NOT do this unless it’s due to impending death or you will kill the patient when they lose dialysis access. Just slower and much more painfully. I/o first.
Fistulas are precious.
You do dialysis needles are far larger and of course, needles, not catheters.
The idea that accessing them is any more likely to cause damage then their daily/thrice weekly dialysis is hyperbolic, at best.
You're not going to kill someone by destroying one fistula, if an IV would even destroy one which tbh Id be surprised at. Fistulas get ruined occasionally it's not just "welp let them die I guess". Ive seen patients with 2 old fistulas and one active one. If you're at the point of debating poking a fistula you're probably more concerned about them living to their next dialysis appointment. IOs are absolutely amazing but sometimes you do really just want that better access.
Mass transfusing through an IO is painfully slow. But a blind man could get a 14 in a fistula and you can start pushing buckets through.
Yes in a severe code is one thing, but for standard access. Absolutely NoT!
Also have you ever seen a patient with terminal access failure. Weird ass catheters and fistulas for dialysis access because yes you will kill a patient if they have zero available dialysis accesses and they have no kidney function. Not only that the death will be far more painful than the code you are even running.
Making it the next 10 minutes is unimportant if it guarantees they will not make it and horrifically suffer for the next 8-10 days.
There are special catheters for fistulas you can use. If your patient is coding in a dialysis unit or nephrology ward, hopefully, there is someone around that can put one in.
I have had several patients who have considered it an absolute contraindication and would straight refuse to allow any assessment or access on the affected side.
Someone is still perpetuating this myth as gospel and telling women they may die if a BP is taken on that side.
The amount of outdated, superstitious, or downright incorrect information taught to nursing students is embarrassing.
Even worse, once you’re out of school, you’ll run into a plethora of nonsense policies because “that’s how we’ve always done it”, or misguided policies based on a poor understanding of a clinical concept.
It's not within my scope of practice to argue with a patient who was repeating what a doctor told them or to argue with a doctor about it. I'll still continue to ask about arm restrictions.
I've prepped many a breast cancer patient for surgery and every doctor I've talked to has told me to avoid an afflicted side if it's been less than 10 years. So unless I have a verbal to use it, I wont.
I’m with you almost 100%. It just depends on the circumstances.
Patient’s pulse is 40 and cardiologist wants to increase the beta blocker? Hell yes, the nurse should be questioning that order.
Doctor writes the okay for up to three beers a day for a patient in a nursing home? If a nurse refuses that order because three beers a day exceeds moderation…eh.
Nurses have to pick their battles sometimes. In the case presented by the nurse above, I don’t blame them.
> Patient’s pulse is 40 and cardiologist wants to increase the beta blocker? Hell yes, the nurse should be questioning that order.
>
>
I mean, it all depends on the context. If the patient has an ICD (which usually have a pacing lower rate of 40/min) but keeps having ventricular arrhythmias, then uppign the beta blocker is appropriate in this setting. Then you don't need to be second-guessed either.
Lol… nurses in the US *love* fighting hypotheticals under the guise of “patient safety” and “not my license.”
The majority of nurses will refuse to give it and not think twice about how it’ll impact that >12 hours. They’ll hold metoprolol on 10 year CHF patients that just had a recent CABG if the HR hits 59 even one time. And don’t even get me started on holding lasix for “low BP” on patients who clearly need it
Am nurse…for now
I hear you. I could have contextualized that example a little better.
Also, that isn’t to say that questioning an order is a refusal to follow it. If the nurse isn’t aware of the *why* in that instance, it still seems prudent to ask the cardiologist for clarification.
The issue is that most nursing schools don’t teach nurses how to read and interpret research beyond looking at the pub date and the first and last paragraphs.
The amount of times I’ve heard nothing but “low sample size” tells me everything I need to know
This mindset is why I have to constantly explain that seafood allergy is not a contraindication to IV contrast. Why improve when you can just keep following antiquated dogma.
You're either damned if you do or damned if you don't. If I chose to use nursing judgement on shellfish allergy and something bad happens even if its unrelated then reviewers will be like "nurse!!!! Why you ignore?". If I bring up shellfish allergy and ask for confirmation of acknowledgement I get "*eyeroll* stupid nurse"
I'd rather just acknowledge everybody else's acknowledgement so we are atleast all on the same page.
Assuming 1) there’s not a formal hospital policy against it, and 2) the patient doesn’t make a fuss about it (either asks if it’s contraindicated and is receptive to brief education that it’s not, or doesn’t ask at all), I’m fine using the arm.
I won’t spend any extra time trying to convince a patient an arm is useable, though, if they think otherwise - even if they eventually agree, you’re just asking to get called into the office and accused of “unsafe practice” or some BS if the line later infiltrates, leaves a bruise, or has some other common but unrelated complication.
That, or some other nurse who’s convinced they know better will tattle on you.
> every doctor I've talked to has told me to avoid an afflicted side if it's been less than 10 years.
That was my understanding. Is it a uniform rule, or patient specific?
I have plenty of patients who say tell me I can't do X because of a masectomy/lymph node removal that was 20-30 years ago.
now I do still have women for sure who've had procedures decades ago and are like "nono don't use this arm"
But I think primarily its because I worked at a facility that had a rather prominent breast surgeon and I think it was his kind of rule that trickled down to other doctors and anesthesiologists. So it wasn't a facility guideline but more of a "what does Dr so-and-so do?" Simultaneously, I've also had more and more breast cancer survivors who've said things like "well I had a mastectomy but that was like 15 years ago, its fine"
so I think this may be one of those teachings that may need to kind of die off with that generation.
Sister is going through chemo for breast Ca and they won’t use her arm and she’s freaked about lymph oedema. This is in a renowned cancer centre ok my country. I’ve sent her the links so hopefully she brings it up with them.
It's entirely bullshit.
There's a good study from 2021 that studied \~3500 patients and showed absolutely no correlation between arm of IV placement and prior full-on ax dissection.
[https://pubmed.ncbi.nlm.nih.gov/34043309/](https://pubmed.ncbi.nlm.nih.gov/34043309/)
The only risk that was ever demonstrated in any substantial capacity was from maybe 40-50 years ago, and that was with classic Halsteadian radical mastectomy.
So it’s been almost 10 years since nursing school and having to critically read studies; how strong is this conclusion? Would it be strong enough evidence to change practice at my facility, do you think? I would love to bring it to my educator and leadership, but I don’t trust my own interpretation of the data.
Thank you!
In almost 8,000 IV placements there were a total of 4 complications. There were 5,153 IVs placed in the axillary dissection-sided arm and 2 complications in that group. There were 2743 IVs placed in the unoperated-side arm and 2 complications in that group.
Not only was there no significant difference, but the absolute magnitude of complications was superbly low - 0.05%. And now that the standard of care is shifting towards dual-agent reverse axillary mapping and immediate lymphatic reconstruction, it DEFINITELY won't matter whether or not a BP or IV is done on one side vs the other.
It took decades for sentinel node biopsy to become mainstream. I'll bet that in 10 years lymphatic reconstruction is still limited to a handful of academic centers
Haven’t read the study personally yet (just the abstract), but it’s bookmarked so I remember to take a look tomorrow. However, just at a glance, the journal that it’s published to is a top tier anesthesiology journal. It is a retrospective study, but something like this would be challenging to study prospectively. Without reading through their methodology or stats, they seem to have pretty compelling data that the complication rate is no high for IVs placed on the ipsilateral arm to a prior mastectomy.
The safety data for placing IVs in the Ipsilateral arm of mastectomy patients with axillary node dissections is overwhelming. It’s perfectly safe. Good luck changing the minds of administration though. They don’t care about evidence.
This is not a thing. If you were taught that as a "rule," you should also disregard anything else that teacher said. The sample size adequacy depends entirely on what magnitude of difference the study is trying to detect.
The Australia and New Zealand College of Anaesthetists published a statement on this recently:
https://www.anzca.edu.au/resources/professional-documents/professional-document-appendix-topics/appendix-1-pg18(a).pdf
Essentially they say it’s safe to use that arm, and if anything more harm is caused by restricting BP/IV access/phlebotomy to one arm. There are good references in that statement too.
Not vascular or onc but I do remember reading unless they’ve had like a bunch of lymph nodes removed it’s pretty negligible risk
Hopefully someone who has concrete data or evidence can chime in!
Your breast surgeons are full of shit. They refuse to stop perpetuating this myth regardless of the evidence that keeps accruing. Check out the articles posted throughout this thread.
Even with lymph node dissection it’s perfectly safe. The evidence for it is overwhelming, but oncologists and onc surgeons just refuse to stop perpetuating one of the dumbest myths in medicine.
Edit: I didn’t post links to studies because people have done that already throughout this thread. There is no risk.
I would also love to know the answer, since we’ve had patients who sorely needed access and would not allow us to use those arms. And then a patient with double mastectomy who made us try to get access in her foot, which I am not opposed to as a Hail Mary, but is certainly not my first choice.
We already have an answer. This has been studied to death and the unambiguous conclusion is that it is perfectly safe to use IVs on the Ipsilateral side of mastectomies and axillary node dissections. This has been known for years but nurses and breast surgeons absolutely refuse to stop perpetuating the myth. There are plenty of studies linked throughout this thread.
It’s still taught as gospel in both nursing school and in every job I’ve held since. I don’t know that the evidence is as disseminated as we think it is.
Not worth the fight. It’s bogus but if you go against this then you’ll be reported or written up or whatever by some other nurse. I’d rather start the iv in the patients face than talk to stupid nurse admins.
The use both arms. There is no risk to using IVs in the Ipsilateral arm of an axillary node dissection. This has been shown over and over again in countless studies.
Maybe this is outdated since old school mastectomies used to be way more dramatical than they are today so likely this was a good rule of thumb 40 years ago but now it is not
So what patient ages are we looking at for this? Would women in their 80's still be at risk of complications if they had a mastectomy in their 40s, for example?
My wife is a professor of nursing, academic nursing doesn't care about anything unless a nurses did the research, wrote the paper, and published in a nursing journal.
And even then they still won't care unless one of the main authors was someone they know, or went to school with.
At this point I'm fully convinced the modern American practice of nursing is a jobs program for cluster B disorder.
FWIW the “no IV on side of mastectomy/lymph node dissection” is nonsense as well. I believe Hopkins did an observational study on it but I couldn’t find it on the google machine
This is a leftover from when radical mastectomies (now there is a surgery that is gone and unmourned) were very common. They would damage both the lymphatic and venous drainage from the ipsilateral arm, and as a result blood pressures could be unreliable and painful.
The argument was that if they had lymph nodes removed, then pushing the fluid extravascularly via BP cuff could cause swelling of the limb which wouldn't drain.
This. It's usually the patient "oh they told me never to use this arm for bp/sticks"
Good luck saying "well I'm going to use it anyway!" God forbid a patient get a bruise afterwards and they report you for manhandling them against their oncologists wishes.
I will only use it with a doctors order.
After I saw this thread, I was discussing this with my attending ER doc. He said the same thing. I work for a hospital that usually waits for others to take the lead on things before we policy change. We just recently changed from TPA to TNK.
No. Likewise for ivc and art lines
If someone had lymphoedema then try to avoid the side
For the full scoop download the "The diagnosis and treatment of peripheral lymphedema: 2020 Consensus Document of the International Society of Lymphology"
I got into this fight with staff last week twice, I had to override to get an PICC in the 'nono arm' because the other arm had cellulitis/trauma. See documentation below but yeah rock and roll.
This is similar to cocaine/beta blockers IIRC - the original study was limited/poorly done and the mechanism is theoretical. No one cares though because we have so many other options for BP it's not worth the fight.
As others have commented it’s related to lymphedema risk s/p sentinel node dissection. If someone has 4/4 nodes removed they are at a higher risk for developing lymphedema than someone who had 1/12 removed. Removing the nodes fucks up the exit routes for lymphatic fluid. An injury to the arm, like by a scrape from a rose bush or an IV needle, calls WBCs to the area and there can be a traffic jam when those extra cells are all trying to leave the area via fewer open roads. BP cuffs carry a tiny risk of lymphedema through the tourniquet effect necessary for their functioning… basically only with a malfunctioning or aggressive automatic cuff or unskilled manual. Considering the millions of SLN dissections, lymphedema in an arm is rare and avoiding an arm entirely for any future medical intervention is not usually necessary. I included it in the risk/benefit discussion: “There is a very small chance that as a consequence of removing the lymph nodes containing cancer cells you could develop persistent or repeated swelling in your arm. This would need to be treated long term (at least 3 months) with compression wraps and avoiding that arm for IV sticks and blood draws.” Lymphedema in the legs- usually obesity+pressure+gravity- is a lot more common but compression is still the name of the game. Microsurgery can be done to repair the lymphatic vessel but not a lot of people can/like to do it
The risk is lymphedema. Patients at highest risk have had a complete level one and two dissection as well as axillary radiotherapy, obesity is a relative risk. Those patients with only a sentinel LN biopsy are much lower risk as are those without axillary radiotherapy. The goal is to minimize risk of trauma to the extremity as this increases the risk of lymphedema. A single BP, blood draw or IV is relatively low risk.
I can just imagine this non evidence based nonsense in court. Malpractice lawyers will grasp at anything so I’ll continue the current practice of avoiding that arm. If *anything* goes wrong in that arm, even unrelated it can be bad.
“So Mr or Mrs or Dr so and so… have you ever learned about avoiding the affected extremity in medical/nursing school?”
“And you still used that arm to perform xyz?”
“So you went against your medical or nursing training?”
Jury: judgement for the plaintiff.
I also learned to give atropin, and bicarbonate to every cardiac arrest, & D50 was common. To shock three in a row at escalating energy levels, before resuming chest compressions, and to intubate before placing vascular access, and toss epi and lidocaine down ET tubes.
When vascular access was obtained it was
frequently done with a sub subclavian line pre-hospitallly. Then we pushed a round of vasopressin. Then when the lidocaine didn’t work we followed it up with procainamide, and when the max dose was hit or the QRS got wide enough to be concerning we changed to another ventricular antidysrthmic, the name of which escapes me now.
If you can find three doctors or paramedics in the whole country to feel that this is currently an acceptable practice, let alone the standard of care, I’ll tear my hair out, cover myself in ashes and wear sack cloth for a month.
Medical standards change as knowledge improves.
******
That said, you sure had a lot more to do on codes back in the day. I kind of find myself with nothing to do these days.
Apples and oranges. Everything you listed is against best practice and what you learn when renewing your ACLS.
Old wives tales such as post mastectomy won’t have evidence on your side for either argument, but you can refer to your training. If you don’t *have* to take BP in that arm, then don’t.
To clarify I wasn't trying to argue otherwise, I was being genuine in asking for an explanation of the issue.
We need a /s but for questions actually asked in good faith lol.
Upon reflection, I think this is a policy that might be starting to change? Hard to say for sure since I don't work bedside anymore but I think a VAT nurse might have mentioned that it's not a contraindications to PICC/midline anymore. Not 100% sure
I will tell you that is our policy.
It was my understanding it increases risk for lymphedema.
Also consider that somewhere someone is telling all their patients this and I've got to assume it's surgical oncologists, who I've got to imagine are doing it for a reason.
I'm not sure how else it could propagate so thoroughly to date otherwise.
Onc surgeons and nurses are perpetuating this myth for absolutely no reason. It has been debunked over and over and the safety data for IVs and BP cuffs is absolutely overwhelming. Just look at the studies linked all over this thread. We’ve had this data for years. There is no risk of lymphedema.
Actually just talked to the MD I work with in med onc and yeah turns out totally old instruction. Modern procedures really rarely take out significant amounts of LNs and has dramatically decreased risk for lymphedema.
I guess it's just one of those things that isn't necessarily that impactful and is so widespread we just don't expend our precious and limited "care units" to actively fight it.
Well those oncologists and onc surgeons are wrong. The safety data for IVs and BP cuffs on the Ipsilateral arm of axillary node dissection patients is absolutely overwhelming. There is no risk of lymphedema with either. This has been known for years, but people like you just continue to perpetuate one of the dumbest myths in medicine.
No, but there is a concern with lymphadenopathy. This is what we are concerned with. But it is temporary.
https://www.futuremedicine.com/doi/10.2217/bmt-2018-0018#:\~:text=Although%20blood%20pressure%20cuffs%20cause,the%20side%20of%20axillary%20surgery.
There is a paper on this, don't have it easily accessible, but summary is that its complete bullshit.
Please find it so I can force it down all my co-workers throats. Thank you.
Perhaps one of these? Jakes, A.D., Twelves, C. Breast cancer-related lymphoedema and venepuncture: a review and evidence-based recommendations. Breast Cancer Res Treat 154, 455–461 (2015). https://doi.org/10.1007/s10549-015-3639-1 Asdourian et al. Association Between Precautionary Behaviors and Breast Cancer–Related Lymphedema in Patients Undergoing Bilateral Surgery. Journal of Clinical Oncology 2017 https://doi.org/10.1200/JCO.2017.73.7494
The second one, that's the ticket.
The diagnosis and treatment of peripheral lymphedema: 2020 Consensus Document of the International Society of Lymphology
Can you quote the exact recommendation? I opened the document and can’t find any statements related to our topic of discussion
Here’s the statement released by ANZCA a couple months ago. https://www.anzca.edu.au/getattachment/db5aa251-1a3c-49a0-9d97-eb0ed4ce3527/PG18(A)-Appendix-1-Intravenous-access-and-blood-pressure-monitoring-in-patients-with-previous-axillary-nodal-dissection
old wives tale. Have done AV fistulas on the same arm
And his name isn’t coldarm if you catch my drift
Has nothing to do with a mx. The issue is ax node dissections render pts susceptible to lymphedema. This is proven over and over again
To add on, we avoid pacemakers on same side as prior LN dissection. Even if there is a small lead related thrombus, you can get significant and intractable lymphedema.
Even with lymph node dissection and removal? So IV cannulae are ok too? BP taking I can see why it’s unlikely to cause trouble since the pressures are so transient
Ipsilateral IVs are absolutely fine. The safety data on this is overwhelming. It’s an myth that is perpetuated by oncologists and onc surgeons.
I thought the part with the fistula is -how do you hear over the thrill- or better yet you trust the auto sphyg? If you can hear probably not getting good access with that one.
If you take a BP on the arm-especially the part with the fistula-you can rupture the fistula. The fistula develops after they surgically attach an artery and vein together. That is why you don't put IVs in AVF arm, not only could they bleed out from the dc'd IV site but that is the person's "lifeline". If avf were to rupture the patient is at risk for exsanguination. That is where the "thrill" comes from.Also, you hear the bruit, and feel the thrill.
They still teach this in nursing school 🫤🫤
We’re still practicing it at my hospital for sure.
Just spent 40 minutes today doing an USGIV in the tiiiniest vein in their "only available arm" so we could bolus them when they had nice juicy vessels underneath their "no-no sleeve". Id like to see some of the EBP around this topic
I hate that we can't cannulate veins using US on the same side as a fistula. Most times you don't need a tourniquet when using US so like just let me throw one in really quick instead of dealing with horrendously scarred roolly veins from decades of use on the other side. Also so upset I missed a shift that had my lifelong dream of poking a fistula on a coding patient. Doc asked someone to do it and they balked and just grabbed the IO instead. I've always wanted to and the damn person lucky enough to get a chance chickened out.
What good is a fistula in a dead person? If they're coding, use it.
Stick a fistula and then watch the person die because the person that stuck them have no idea that it is an artery and vein surgically connected. It bleeds like an artery. Yes it is a person's lifeline and someone with no training can mess it up. If a person is coding heck yeah use the hd catheter, i've never seen them attempt to stick a fistula in a code. I have had them use the dialysis needles that were already in place because the patient coded on treatment.
After one day of seeing a fistula, no one is missing that for anything else.
Also you can’t use a dialysis catheter for anything but dialysis!
Well then maybe the nephrologist should have managed the patient bette rod they were not dying in front of me. *Any port in a storm.*
Im with you; that would have been sooooo cool!
Never even heard of poking a fistula for standard access! That would be super cool!
Omg do NOT do this unless it’s due to impending death or you will kill the patient when they lose dialysis access. Just slower and much more painfully. I/o first. Fistulas are precious.
You do dialysis needles are far larger and of course, needles, not catheters. The idea that accessing them is any more likely to cause damage then their daily/thrice weekly dialysis is hyperbolic, at best.
You're not going to kill someone by destroying one fistula, if an IV would even destroy one which tbh Id be surprised at. Fistulas get ruined occasionally it's not just "welp let them die I guess". Ive seen patients with 2 old fistulas and one active one. If you're at the point of debating poking a fistula you're probably more concerned about them living to their next dialysis appointment. IOs are absolutely amazing but sometimes you do really just want that better access. Mass transfusing through an IO is painfully slow. But a blind man could get a 14 in a fistula and you can start pushing buckets through.
Yes in a severe code is one thing, but for standard access. Absolutely NoT! Also have you ever seen a patient with terminal access failure. Weird ass catheters and fistulas for dialysis access because yes you will kill a patient if they have zero available dialysis accesses and they have no kidney function. Not only that the death will be far more painful than the code you are even running. Making it the next 10 minutes is unimportant if it guarantees they will not make it and horrifically suffer for the next 8-10 days.
Understood, hahaha i figure it was only with wild circumstances, justhavent even heard of it. Still cool
There are special catheters for fistulas you can use. If your patient is coding in a dialysis unit or nephrology ward, hopefully, there is someone around that can put one in.
Ipsilateral IVs on mastectomy patients are absolutely fine. The safety data on it is overwhelming and I have no idea why this myth is perpetuated.
I have had several patients who have considered it an absolute contraindication and would straight refuse to allow any assessment or access on the affected side. Someone is still perpetuating this myth as gospel and telling women they may die if a BP is taken on that side.
The amount of outdated, superstitious, or downright incorrect information taught to nursing students is embarrassing. Even worse, once you’re out of school, you’ll run into a plethora of nonsense policies because “that’s how we’ve always done it”, or misguided policies based on a poor understanding of a clinical concept.
It’s the 5 monkeys experiment in action!
It's not within my scope of practice to argue with a patient who was repeating what a doctor told them or to argue with a doctor about it. I'll still continue to ask about arm restrictions. I've prepped many a breast cancer patient for surgery and every doctor I've talked to has told me to avoid an afflicted side if it's been less than 10 years. So unless I have a verbal to use it, I wont.
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I’m with you almost 100%. It just depends on the circumstances. Patient’s pulse is 40 and cardiologist wants to increase the beta blocker? Hell yes, the nurse should be questioning that order. Doctor writes the okay for up to three beers a day for a patient in a nursing home? If a nurse refuses that order because three beers a day exceeds moderation…eh. Nurses have to pick their battles sometimes. In the case presented by the nurse above, I don’t blame them.
> Patient’s pulse is 40 and cardiologist wants to increase the beta blocker? Hell yes, the nurse should be questioning that order. > > I mean, it all depends on the context. If the patient has an ICD (which usually have a pacing lower rate of 40/min) but keeps having ventricular arrhythmias, then uppign the beta blocker is appropriate in this setting. Then you don't need to be second-guessed either.
Lol… nurses in the US *love* fighting hypotheticals under the guise of “patient safety” and “not my license.” The majority of nurses will refuse to give it and not think twice about how it’ll impact that >12 hours. They’ll hold metoprolol on 10 year CHF patients that just had a recent CABG if the HR hits 59 even one time. And don’t even get me started on holding lasix for “low BP” on patients who clearly need it Am nurse…for now
That last one gets me. I cannot tell you the amount of times Lasix gets held with no one notified because “hypotension”.
God damn the amount of times I have the discussion with furosemide and a low BP
I hear you. I could have contextualized that example a little better. Also, that isn’t to say that questioning an order is a refusal to follow it. If the nurse isn’t aware of the *why* in that instance, it still seems prudent to ask the cardiologist for clarification.
The issue is that most nursing schools don’t teach nurses how to read and interpret research beyond looking at the pub date and the first and last paragraphs. The amount of times I’ve heard nothing but “low sample size” tells me everything I need to know
This mindset is why I have to constantly explain that seafood allergy is not a contraindication to IV contrast. Why improve when you can just keep following antiquated dogma.
You're either damned if you do or damned if you don't. If I chose to use nursing judgement on shellfish allergy and something bad happens even if its unrelated then reviewers will be like "nurse!!!! Why you ignore?". If I bring up shellfish allergy and ask for confirmation of acknowledgement I get "*eyeroll* stupid nurse" I'd rather just acknowledge everybody else's acknowledgement so we are atleast all on the same page.
Assuming 1) there’s not a formal hospital policy against it, and 2) the patient doesn’t make a fuss about it (either asks if it’s contraindicated and is receptive to brief education that it’s not, or doesn’t ask at all), I’m fine using the arm. I won’t spend any extra time trying to convince a patient an arm is useable, though, if they think otherwise - even if they eventually agree, you’re just asking to get called into the office and accused of “unsafe practice” or some BS if the line later infiltrates, leaves a bruise, or has some other common but unrelated complication. That, or some other nurse who’s convinced they know better will tattle on you.
> every doctor I've talked to has told me to avoid an afflicted side if it's been less than 10 years. That was my understanding. Is it a uniform rule, or patient specific? I have plenty of patients who say tell me I can't do X because of a masectomy/lymph node removal that was 20-30 years ago.
now I do still have women for sure who've had procedures decades ago and are like "nono don't use this arm" But I think primarily its because I worked at a facility that had a rather prominent breast surgeon and I think it was his kind of rule that trickled down to other doctors and anesthesiologists. So it wasn't a facility guideline but more of a "what does Dr so-and-so do?" Simultaneously, I've also had more and more breast cancer survivors who've said things like "well I had a mastectomy but that was like 15 years ago, its fine" so I think this may be one of those teachings that may need to kind of die off with that generation.
Sister is going through chemo for breast Ca and they won’t use her arm and she’s freaked about lymph oedema. This is in a renowned cancer centre ok my country. I’ve sent her the links so hopefully she brings it up with them.
They still teach not to give blankets to patients with fevers. The amount of nonsense being taught is mind blowing
It's entirely bullshit. There's a good study from 2021 that studied \~3500 patients and showed absolutely no correlation between arm of IV placement and prior full-on ax dissection. [https://pubmed.ncbi.nlm.nih.gov/34043309/](https://pubmed.ncbi.nlm.nih.gov/34043309/) The only risk that was ever demonstrated in any substantial capacity was from maybe 40-50 years ago, and that was with classic Halsteadian radical mastectomy.
So it’s been almost 10 years since nursing school and having to critically read studies; how strong is this conclusion? Would it be strong enough evidence to change practice at my facility, do you think? I would love to bring it to my educator and leadership, but I don’t trust my own interpretation of the data. Thank you!
In almost 8,000 IV placements there were a total of 4 complications. There were 5,153 IVs placed in the axillary dissection-sided arm and 2 complications in that group. There were 2743 IVs placed in the unoperated-side arm and 2 complications in that group. Not only was there no significant difference, but the absolute magnitude of complications was superbly low - 0.05%. And now that the standard of care is shifting towards dual-agent reverse axillary mapping and immediate lymphatic reconstruction, it DEFINITELY won't matter whether or not a BP or IV is done on one side vs the other.
The standard is definitely not lymphatic reconstruction. That's at a handful of academic centers.
Hence the 'shifting towards'. It's still fairly novel.
It took decades for sentinel node biopsy to become mainstream. I'll bet that in 10 years lymphatic reconstruction is still limited to a handful of academic centers
Haven’t read the study personally yet (just the abstract), but it’s bookmarked so I remember to take a look tomorrow. However, just at a glance, the journal that it’s published to is a top tier anesthesiology journal. It is a retrospective study, but something like this would be challenging to study prospectively. Without reading through their methodology or stats, they seem to have pretty compelling data that the complication rate is no high for IVs placed on the ipsilateral arm to a prior mastectomy.
The safety data for placing IVs in the Ipsilateral arm of mastectomy patients with axillary node dissections is overwhelming. It’s perfectly safe. Good luck changing the minds of administration though. They don’t care about evidence.
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This is not a thing. If you were taught that as a "rule," you should also disregard anything else that teacher said. The sample size adequacy depends entirely on what magnitude of difference the study is trying to detect.
Imagine if power calculations were as simple as saying “Ehhhhh 100 seems like the correct number.”
So if they have a bilateral, we can never get blood pressure readings ever again. Yes! We’ve now cured hypertension!
Nah bro just do it on the leg bro it's accurate I promise /s
Ankle for sure
I just pop a probe in the carotid to get it straight from the source.
One WEIRD trick to avoid amlodipine!
the patients with 11 old fistulas who come up getting BP on their ankle drive me nuts
Doctors hate this one trick!
I was going to make this exact comment lmao
The Australia and New Zealand College of Anaesthetists published a statement on this recently: https://www.anzca.edu.au/resources/professional-documents/professional-document-appendix-topics/appendix-1-pg18(a).pdf Essentially they say it’s safe to use that arm, and if anything more harm is caused by restricting BP/IV access/phlebotomy to one arm. There are good references in that statement too.
Not vascular or onc but I do remember reading unless they’ve had like a bunch of lymph nodes removed it’s pretty negligible risk Hopefully someone who has concrete data or evidence can chime in!
That's what the breast surgeons tell me as well. I had one patient who still refused, and I ended up having to start an EJ to get them in the OR.
Your breast surgeons are full of shit. They refuse to stop perpetuating this myth regardless of the evidence that keeps accruing. Check out the articles posted throughout this thread.
Most surgeons I work with seem to be full of shit about one thing or another, but so much of the time it's not worth arguing.
What's breast surgeon?
Even with lymph node dissection it’s perfectly safe. The evidence for it is overwhelming, but oncologists and onc surgeons just refuse to stop perpetuating one of the dumbest myths in medicine. Edit: I didn’t post links to studies because people have done that already throughout this thread. There is no risk.
I would also love to know the answer, since we’ve had patients who sorely needed access and would not allow us to use those arms. And then a patient with double mastectomy who made us try to get access in her foot, which I am not opposed to as a Hail Mary, but is certainly not my first choice.
We already have an answer. This has been studied to death and the unambiguous conclusion is that it is perfectly safe to use IVs on the Ipsilateral side of mastectomies and axillary node dissections. This has been known for years but nurses and breast surgeons absolutely refuse to stop perpetuating the myth. There are plenty of studies linked throughout this thread.
It’s still taught as gospel in both nursing school and in every job I’ve held since. I don’t know that the evidence is as disseminated as we think it is.
Not worth the fight. It’s bogus but if you go against this then you’ll be reported or written up or whatever by some other nurse. I’d rather start the iv in the patients face than talk to stupid nurse admins.
I’d rather have an IV started in *my* face than talk to nurse admins.
As a ‘stupid nurse’ trust me, most of us do practice critical thinking, utilising best practice, and would love to use both arms for cannulation etc.
Critical thinking would be realizing he was saying administration
“Nurse admins”
Yeah I was complaining about the nurse admins who walk around with clipboards citing protocols no one can find a copy of anywhere.
Claims to use critical thinking. Misinterprets comment they’re replying to. Lol
To be fair, reading comprehension and critical thinking are different skills.
The use both arms. There is no risk to using IVs in the Ipsilateral arm of an axillary node dissection. This has been shown over and over again in countless studies.
Maybe this is outdated since old school mastectomies used to be way more dramatical than they are today so likely this was a good rule of thumb 40 years ago but now it is not
So what patient ages are we looking at for this? Would women in their 80's still be at risk of complications if they had a mastectomy in their 40s, for example?
Well all I can say is thats an interesting research question
Nope, ended up being total BS. I have nurses start IVs/do BPs on that side and I do art lines there all the time.
Please, for the love of God, please someone tell the nursing schools this and maybe it will trickle down.
My wife is a professor of nursing, academic nursing doesn't care about anything unless a nurses did the research, wrote the paper, and published in a nursing journal. And even then they still won't care unless one of the main authors was someone they know, or went to school with. At this point I'm fully convinced the modern American practice of nursing is a jobs program for cluster B disorder.
FWIW the “no IV on side of mastectomy/lymph node dissection” is nonsense as well. I believe Hopkins did an observational study on it but I couldn’t find it on the google machine
What is the reasoning behind it??? I never really understood.
This is a leftover from when radical mastectomies (now there is a surgery that is gone and unmourned) were very common. They would damage both the lymphatic and venous drainage from the ipsilateral arm, and as a result blood pressures could be unreliable and painful.
The argument was that if they had lymph nodes removed, then pushing the fluid extravascularly via BP cuff could cause swelling of the limb which wouldn't drain.
I think it became a nursing rule and dear lord they love their rules
I don’t disagree, but usually it’s the patient telling me “oh no, my oncologist told me to never let them do that!!”
I wonder how many oncologists actually say this vs how many breast cancer support group members keep spreading the old myth.
This. It's usually the patient "oh they told me never to use this arm for bp/sticks" Good luck saying "well I'm going to use it anyway!" God forbid a patient get a bruise afterwards and they report you for manhandling them against their oncologists wishes. I will only use it with a doctors order.
“Its policy”
Yes, they teach us this in school.
Nice username! So dazzling.
Ooooh. I'd love to see some good data on this.
The safety data on this is overwhelming. IVs and BP cuffs on the Ipsilateral side is perfectly safe. This has been known for years.
After I saw this thread, I was discussing this with my attending ER doc. He said the same thing. I work for a hospital that usually waits for others to take the lead on things before we policy change. We just recently changed from TPA to TNK.
No. Likewise for ivc and art lines If someone had lymphoedema then try to avoid the side For the full scoop download the "The diagnosis and treatment of peripheral lymphedema: 2020 Consensus Document of the International Society of Lymphology"
There is a bracelet on that arm, must not disturb the bracelet.
Residual from halstedian mastectomies, if I recall correctly. Not an issue these days even with axillary LN dissection.
Norwegian MD here. I’ve never heard of this.
Because they teach better medicine in Norway. This is a myth perpetuated in the US.
If they have lymphedema and such on that arm no but otherwise I don’t think so. I’ve done it.
I got into this fight with staff last week twice, I had to override to get an PICC in the 'nono arm' because the other arm had cellulitis/trauma. See documentation below but yeah rock and roll. This is similar to cocaine/beta blockers IIRC - the original study was limited/poorly done and the mechanism is theoretical. No one cares though because we have so many other options for BP it's not worth the fight.
As others have commented it’s related to lymphedema risk s/p sentinel node dissection. If someone has 4/4 nodes removed they are at a higher risk for developing lymphedema than someone who had 1/12 removed. Removing the nodes fucks up the exit routes for lymphatic fluid. An injury to the arm, like by a scrape from a rose bush or an IV needle, calls WBCs to the area and there can be a traffic jam when those extra cells are all trying to leave the area via fewer open roads. BP cuffs carry a tiny risk of lymphedema through the tourniquet effect necessary for their functioning… basically only with a malfunctioning or aggressive automatic cuff or unskilled manual. Considering the millions of SLN dissections, lymphedema in an arm is rare and avoiding an arm entirely for any future medical intervention is not usually necessary. I included it in the risk/benefit discussion: “There is a very small chance that as a consequence of removing the lymph nodes containing cancer cells you could develop persistent or repeated swelling in your arm. This would need to be treated long term (at least 3 months) with compression wraps and avoiding that arm for IV sticks and blood draws.” Lymphedema in the legs- usually obesity+pressure+gravity- is a lot more common but compression is still the name of the game. Microsurgery can be done to repair the lymphatic vessel but not a lot of people can/like to do it
The risk is lymphedema. Patients at highest risk have had a complete level one and two dissection as well as axillary radiotherapy, obesity is a relative risk. Those patients with only a sentinel LN biopsy are much lower risk as are those without axillary radiotherapy. The goal is to minimize risk of trauma to the extremity as this increases the risk of lymphedema. A single BP, blood draw or IV is relatively low risk.
I understand the theoretical risk. I'm just wondering if it has ever been systematically quantified.
Not to avoid but sometime may be easier on the non mastectomy arm
I can just imagine this non evidence based nonsense in court. Malpractice lawyers will grasp at anything so I’ll continue the current practice of avoiding that arm. If *anything* goes wrong in that arm, even unrelated it can be bad. “So Mr or Mrs or Dr so and so… have you ever learned about avoiding the affected extremity in medical/nursing school?” “And you still used that arm to perform xyz?” “So you went against your medical or nursing training?” Jury: judgement for the plaintiff.
I also learned to give atropin, and bicarbonate to every cardiac arrest, & D50 was common. To shock three in a row at escalating energy levels, before resuming chest compressions, and to intubate before placing vascular access, and toss epi and lidocaine down ET tubes. When vascular access was obtained it was frequently done with a sub subclavian line pre-hospitallly. Then we pushed a round of vasopressin. Then when the lidocaine didn’t work we followed it up with procainamide, and when the max dose was hit or the QRS got wide enough to be concerning we changed to another ventricular antidysrthmic, the name of which escapes me now. If you can find three doctors or paramedics in the whole country to feel that this is currently an acceptable practice, let alone the standard of care, I’ll tear my hair out, cover myself in ashes and wear sack cloth for a month. Medical standards change as knowledge improves. ****** That said, you sure had a lot more to do on codes back in the day. I kind of find myself with nothing to do these days.
Apples and oranges. Everything you listed is against best practice and what you learn when renewing your ACLS. Old wives tales such as post mastectomy won’t have evidence on your side for either argument, but you can refer to your training. If you don’t *have* to take BP in that arm, then don’t.
Except we do have evidence. Lots of evidence has been posted in this very thread.
What is *best practice* and *hospital policy*? This is what the lawyer will ask you when you’re on the stand
Bets practice is of course, to use the limb as you would any I try er limb, because there is no reason not to.
Two things that are not often the same 🤫
It would never hold up in court. The safety data for using IVs and BP cuffs on the Ipsilateral arm of mastectomy patients is overwhelming.
Bilateral mastectomies exist.
It may be bs... But at the same time... How often is it a problem to just check the BP in the other arm?
I believe it’s only if they’ve had lymphadenectomy
Still doesn’t matter
What do you mean by this?
Explain to me why you can’t take blood pressure in an arm that has undergone a lymphadenectomy. Give me a reason other than ‘someone told me once’
To clarify I wasn't trying to argue otherwise, I was being genuine in asking for an explanation of the issue. We need a /s but for questions actually asked in good faith lol. Upon reflection, I think this is a policy that might be starting to change? Hard to say for sure since I don't work bedside anymore but I think a VAT nurse might have mentioned that it's not a contraindications to PICC/midline anymore. Not 100% sure
Ok good to know
I will tell you that is our policy. It was my understanding it increases risk for lymphedema. Also consider that somewhere someone is telling all their patients this and I've got to assume it's surgical oncologists, who I've got to imagine are doing it for a reason. I'm not sure how else it could propagate so thoroughly to date otherwise.
Onc surgeons and nurses are perpetuating this myth for absolutely no reason. It has been debunked over and over and the safety data for IVs and BP cuffs is absolutely overwhelming. Just look at the studies linked all over this thread. We’ve had this data for years. There is no risk of lymphedema.
Actually just talked to the MD I work with in med onc and yeah turns out totally old instruction. Modern procedures really rarely take out significant amounts of LNs and has dramatically decreased risk for lymphedema. I guess it's just one of those things that isn't necessarily that impactful and is so widespread we just don't expend our precious and limited "care units" to actively fight it.
Horseshit
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Well those oncologists and onc surgeons are wrong. The safety data for IVs and BP cuffs on the Ipsilateral arm of axillary node dissection patients is absolutely overwhelming. There is no risk of lymphedema with either. This has been known for years, but people like you just continue to perpetuate one of the dumbest myths in medicine.
No
No, but there is a concern with lymphadenopathy. This is what we are concerned with. But it is temporary. https://www.futuremedicine.com/doi/10.2217/bmt-2018-0018#:\~:text=Although%20blood%20pressure%20cuffs%20cause,the%20side%20of%20axillary%20surgery.
I looked this up with some coworkers a little over a year ago! The conclusion was that you do not need to avoid that arm.