1. Evidence in The ED: Is venipuncture contraindicated post-mastectomy? Brynn Utley, MDEM3 01/16/2013 Departments of Emergency Medicine University of Pennsylvania Health System

2. References 1.Winge, C et al. Journal of Clinical Nursing. 2010 May;19(9-10):1270-4 2.Mak, SS et al. Nursing Research. 2008 Nov-Dec;57(6):416-25 3.Clark, B et cl. European Journal of Cancer Care. 1998 Jun;7(2):97-8.

3. Post-Mastectomy Lymphedema -Accumulation of fluid in soft tissue -Occurs in up to 40% of pts following breast cancer surgery. Risk factors may include: -involvement of lymph nodes -axillary dissection -radiotherapy -Etiology not well defined -? Primary trauma to lymph system -? Increased infection due lymph disfunction

4. Winge et al, 2010 Design/Methods: -1 year period at one Stockholm hospital -Retrospective questionnaire -Sample population: breast CA pts s/p axillary node dissection

5. Winge et al, 2010 Design/Methods: -Surveys sent to 348 of 388 eligible pts (40 deceased at time of study) -89.4% response rate

6. Winge et al, 2010 Results: -88.9% of sample had ipsilateral IVP (including blood sample, IV infusion, or other/unknown intervention) Reported complications Infection1 (0.3%) Swollen Arm5 ( 1.6%) Redness0 Fever0 Ithcing, aching, bruise, vomiting 6 (1.9)

7. Winge et al, 2010 Conclusions: -If blood draw or IV injection is performed on the ipsalateral side following axillary surgery there is a low risk for complications.

8. Mak, S et al, 2008 Design/Methods: -Case-Control Study to evaluate risk of lymphedema following ALND -Included ethnically Chinese women recruited at follow-up onco clinic -101 1:1 pairs matched by 1) time from ax dissection to recruitment 2) axillary radiotherapy or not 3) cancer stage

9. Mak, S et al, 2008 Design/Methods: --Lymphedema = arm circumference measurements compared to opposite are -<3cm = mild -3-5cm = moderate ->5cm = severe -Arm Questionnaire used to gather data on potential risk factors (incl medical procedures)

10. Mak, S et al, 2008 Results: -Significant factors in univariate analysis: -BMI at recruitment (control 22.4 v case 23.5, p=0.03) -Age at recruitment (control 50.3 v case 53.0, p=0.3) -Previous infection/inflammation (control 14 v case 37, p=0.0003) *Medical Procedures, including blood draws or BP measurements, was not significant (control 31 v 21, p=0.11)

11. Mak, S et al, 2008 Results: -In comparing mild to moderate/severe lymphedema (ie, 0-3cm difference in arm circumference vs >3cm): Medical procedures No to mild N=128 Mod to severe N=74 p 39 (30.5%)13 (17.6%)0.046

12. Mak, S et al, 2008 Conclusions: -While age, BMI, dominant vs nondominant hand, and hx of prior infection may be risk factors, ipsilateral medical procedures was not a risk factor.

13. Clark, B et al, 1998 Design/Methods -Prospective single center study, n=183 (of 295 eligible with 27 deceased/unable to participate, 18 lost to f/u, 18 declined f/u) -Arm measurements taken pre and post surgery (lympedema determined by measured arm volume, or clinical dx)

14. Clark, B et al, 1998 Design/Methods - Looked at 4 dichotomous variables -BMI > or <26 -Radiotherapy yes/no -Node status pos/neg -Skin puncture yes/no (any intentional puncture by health professional or pt including FS glucose) -Lymphema rates compared at 3-year follow-up

15. Clark, B et al, 1998 Results: -20.7% developed lymphedema -Skin puncutre, BMI, mastectomy were significant (but NOT age, node status, radiotherapy)

16. Clark, B et al, 1998 Conclusions: -Avoid accidental and non-accidental skin puncture to reduce risk of lymphedema

17. HUPism Ipsilateral venipuncture on post- mastectomy patients should be avoided when possible, but until better evidence is available the practice should NOT be contraindicated.