Continuous non-invasive BP monitoring (eg ClearSite) and Limb Precautions

[bonzie37]

Does anyone know if continuous non-invasive BP monitoring (such as ClearSite) is safe for use in a patient with limb precautions (like s/p mastectomy)? I know there is debate about how IVs and regular NIBP cuffs are probably safe in those patients, but I am asking specifically about the ClearSite and other similar systems.

Yes, I tried to find this information elsewhere before posting here and yes, this is for oral boards studying. Thanks!

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[dhb]

debate

Between people that have no clue in physiology.

 

[IMGASMD]

Not sure if this is for real.......

 

[dchz]

Not sure if this is for real.......

I was typing up a serious reeply to this, i might have gotten trolled. good call !

 

[bonzie37]

This is real. I had this practice oral board scenario below:

46yoF s/p right mastectomy and LN dissection coming in for left shoulder surgery in beach chair position as an outpatient -- how would you monitor BP? I figure you can't use a NIBP on the surgical arm and the other arm has limb precautions. The leg is not accurate so I don't think I would want that much error when I'm concerned about cerebral perfusion due to the positioning. Lastly, I would like to avoid an arterial line for an outpatient procedure in someone who might not otherwise need it, though I guess a DP a-line would be possible but I have never actually put one in.

I would think ClearSite would not effect lymphatic drainage from the arm since it is so distal and it would be more accurate reading since I could zero at the external auditory meatus but I don't know if this is the right way of thinking. Or if an oral board examiner would just say "the hospital doesn't have a ClearSite or any similar equipment. Just a-line or NIBP."

 

[Mman]

This is real. I had this practice oral board scenario below:

46yoF s/p right mastectomy and LN dissection coming in for left shoulder surgery in beach chair position as an outpatient -- how would you monitor BP? I figure you can't use a NIBP on the surgical arm and the other arm has limb precautions. The leg is not accurate so I don't think I would want that much error when I'm concerned about cerebral perfusion due to the positioning. Lastly, I would like to avoid an arterial line for an outpatient procedure in someone who might not otherwise need it, though I guess a DP a-line would be possible but I have never actually put one in.

I would think ClearSite would not effect lymphatic drainage from the arm since it is so distal and it would be more accurate reading since I could zero at the external auditory meatus but I don't know if this is the right way of thinking. Or if an oral board examiner would just say "the hospital doesn't have a ClearSite or any similar equipment. Just a-line or NIBP."

femoral art line and put the transducer up at her earlobe

 

[Ronin786]

It's probably just as useful as in somebody with no limb precautions. I.e. absolutely worthless and full of ****.

 

[IMGASMD]

I was typing up a serious reeply to this, i might have gotten trolled. good call !

I am still not sure.

Since there was a post from the OP regarding getting a PhD in Social work. This was also a question that was discussed recently on SDN.

But if it was for real....

Clinical Inquiry-In women who have undergone breast cancer surgery, including lymph node removal, do blood pressure measurements taken in the ipsilateral arm increase the risk of lymphedema?

Throughout the healthcare industry fears of taking blood pressure in the arm of patients who have undergone breast cancer surgery have been propagated for decades and continue to be recommended by multiple medical societies and healthcare organizations. ...

www.ncbi.nlm.nih.gov

Just use the arm.

 

[deleted162650]

Just put it on the leg and do the math for the elevation difference. Use the MAP not the SBP.

 

[Iso4ane]

Just put it on the leg and do the math for the

What about doing it awake-ish. if the the patient is talking, the patient is perfuming their brain.

 

[deleted162650]

What about doing it awake-ish. if the the patient is talking, the patient is perfuming their brain.

Umm, f***k that. Just put the patient in beach chair and check NIBPs on the operative arm and a leg pre-induction to see the difference. Repeat this after induction before they prep just for consistency’s sake. Now you know what to keep leg BP for a corresponding arm BP.

Or tell the surgeon to get with the times and do it lateral.

 

[fakin' the funk]

Umm, f***k that. Just put the patient in beach chair and check NIBPs on the operative arm and a leg pre-induction to see the difference. Repeat this after induction before they prep just for consistency’s sake. Now you know what to keep leg BP for a corresponding arm BP.

Or tell the surgeon to get with the times and do it lateral.

Great post

 

[nimbus]

Impact of the Beach Chair Position on Cerebral Perfusion: What Do We Know So Far?

Arthroscopic repair of the shoulder is one of the most commonly performed surgical procedures in the United States. Although shoulder surgery can be

www.apsf.org

 

[fakin' the funk]

How about... Educate the patient on her options and let her decide? **** is all theoretical anyway and you're doing good care whether it's putting in radial art line on mastectomy arm or doing q5 nibp on that arm. Safety first, let the patient decide what risks they want.

 

[DM27]

Regarding limb precautions and NIBP usage. I am not aware of any evidence at all that even hinted at a link between NIBP cuff usage and issues in individuals w/mastectomy and lymph node dissection, AV fistulas/grafts, PICC lines, or what-have-you. The pressure of the NIBP cuff on the arm is likely not appreciably worse than the continued pressure of the individual sleeping on that arm, and no one is policing for that.

Despite what I said above, my personal practice is I will honor limb precautions when stated simply because anything that ever happens will be blamed on that NIBP cuff if anyone remarks on the choice during the case. The order in which I care (in descending order) is PICC line (because it is actually likely in the area compressed the cuff), AV Graft, AV Fistula, some sort of surgery with/or just lymph node dissection, stroke.

AV Fistula is where I draw the line in terms of when I will just use a cuff on that limb anyways if I have issues getting reliable BP reading elsewhere (so lymph node and stroke will get the cuff if needed).

 

[vector2]

Regarding limb precautions and NIBP usage. I am not aware of any evidence at all that even hinted at a link between NIBP cuff usage and issues in individuals w/mastectomy and lymph node dissection, AV fistulas/grafts, PICC lines, or what-have-you. The pressure of the NIBP cuff on the arm is likely not appreciably worse than the continued pressure of the individual sleeping on that arm, and no one is policing for that.

Despite what I said above, my personal practice is I will honor limb precautions when stated simply because anything that ever happens will be blamed on that NIBP cuff if anyone remarks on the choice during the case. The order in which I care (in descending order) is PICC line (because it is actually likely in the area compressed the cuff), AV Graft, AV Fistula, some sort of surgery with/or just lymph node dissection, stroke.

AV Fistula is where I draw the line in terms of when I will just use a cuff on that limb anyways if I have issues getting reliable BP reading elsewhere (so lymph node and stroke will get the cuff if needed).

Please don't put a BP cuff anywhere near a fistula...


"
Avoid pressure of any kind on your fistula arm, as it can lead to thrombosis, especially in a condition of low blood pressure.

You should avoid the following:
• Wearing tight clothing or restricting objects such as watches or bracelets which could cause a compression of the fistula.
• Sleeping on your access arm, as it can lead to transitory fistula kinking and a reduction of the blood flow.
• Strong bending of your fistula arm.
• Measuring your blood pressure in the fistula arm with a blood pressure meter, as inflating the cuff induces a compression of the blood vessels.
• Drawing blood or injections, as afterwards haemostasis has to be performed. In addition, unqualified personnel could potentially damage the fistula.
"

 

[DM27]

Please don't put a BP cuff anywhere near a fistula...


"
Avoid pressure of any kind on your fistula arm, as it can lead to thrombosis, especially in a condition of low blood pressure.

You should avoid the following:
• Wearing tight clothing or restricting objects such as watches or bracelets which could cause a compression of the fistula.
• Sleeping on your access arm, as it can lead to transitory fistula kinking and a reduction of the blood flow.
• Strong bending of your fistula arm.
• Measuring your blood pressure in the fistula arm with a blood pressure meter, as inflating the cuff induces a compression of the blood vessels.
• Drawing blood or injections, as afterwards haemostasis has to be performed. In addition, unqualified personnel could potentially damage the fistula.
"

Yeah that is not something I do which is why I draw the line at fistulas. Out of curiosity though are you aware of a study that supports the idea that the BP cuff will damage a fistula distal to it?

 

[vector2]

Yeah that is not something I do which is why I draw the line at fistulas. Out of curiosity though are you aware of a study that supports the idea that the BP cuff will damage a fistula distal to it?

It's well-known that venous stenosis/outflow obstruction is the most common cause of late fistula thrombosis and failure. Testing a BP cuff hypothesis would be unethical imo when we already know this much about the basic science and risk factors. Not to mention, the MAP isn't going to be accurate anyway.

 

[DM27]

It would have to have been either an animal study or from not long after the initial application of fistulas for dialysis if this was not an already theorized potential complication. Even the lowest level of evidence like a case report describing AV fistula thrombosis occurring after someone put an NIBP cuff one that arm I would count as at least useful .

Regardless a common theme in medicine is the prevailing knowledge conclusion being proven startlingly wrong when subjected to actual research.

 

[vector2]

@DM27 I really dont get what point you're trying to make here. Are you trying to imply that we do not need to be tiptoeing around a delicate vascular anastomosis, notoriously sensitive to changes in flow, which are constantly thrombosing and/or failing all the time? And again, the BP in the AVF arm wouldn't be accurate anyway so I'm not sure why you care.

Also, I don't think the point about dearth of evidence about slapping a BP cuff on an AVF vs previous mastectomy/ lymph node dissection is in any way analogous. Limb protection for LND is pure voodoo (barring massive trauma) at least as far as I can gather from the literature and talking to breast surgeons.

OTOH, wanting a study about BP cuffs and AVF is like wanting a study proving the efficacy of parachutes.

 

[vector2]

Medline ® Abstract for Reference 88 of 'Risk factors for hemodialysis arteriovenous fistula failure'

88PubMedTIObesity and hemodialysis vascular access failure.
AUPlumb TJ, Adelson AB, Groggel GC, Johanning JM, Lynch TG, Lund B SOAm J Kidney Dis. 2007;50(3):450.
A variety of factors have been proposed to explain arteriovenous fistula primary failures in patients undergoing hemodialysis, including obesity, diabetes mellitus, female sex, and the absence of preoperative vein mapping. In this report, we describe 2 women for whom premature upper-extremity arteriovenous fistula failures occurred in the setting of venographic evidence of soft-tissue compression of the venous outflow with the patient's arm in the adducted position. In each instance, preoperative noninvasive duplex vein mapping showed veins of adequate diameter (0.28 to 0.54 cm), and further evaluation showed no evidence of a hypercoagulable state. Upper-extremity venography was used to assess central venous patency and fully assess the venous vasculature. Unlike the widely patent venous systems seen in the abducted position, venography performed with the upper extremities in adduction showed marked narrowing of the brachial and/or axillary veins. The hemodynamic effects of this narrowing were readily apparent in patient 2 with the appearance of collateral filling of the cephalic vein in the adducted position. Patient 1 had a body mass index of 39 kg/m(2), and patient 2 had a body mass index of 34 kg/m(2). Each patient had excess axillary soft tissue that appeared to compress the venous outflow in adduction. To our knowledge, this is the first report to radiographically document soft-tissue compression of the venous outflow of the upper extremity in the adducted position, suggesting a mechanism whereby obesity, or at least excess axillary fat, can lead to premature hemodialysis vascular access failures.
ADUniversity of Nebraska Medical Center, Omaha, NE 68198-3040, USA. [email protected]

 

[DM27]

Medline ® Abstract for Reference 88 of 'Risk factors for hemodialysis arteriovenous fistula failure'

88PubMedTIObesity and hemodialysis vascular access failure.
AUPlumb TJ, Adelson AB, Groggel GC, Johanning JM, Lynch TG, Lund B SOAm J Kidney Dis. 2007;50(3):450.
A variety of factors have been proposed to explain arteriovenous fistula primary failures in patients undergoing hemodialysis, including obesity, diabetes mellitus, female sex, and the absence of preoperative vein mapping. In this report, we describe 2 women for whom premature upper-extremity arteriovenous fistula failures occurred in the setting of venographic evidence of soft-tissue compression of the venous outflow with the patient's arm in the adducted position. In each instance, preoperative noninvasive duplex vein mapping showed veins of adequate diameter (0.28 to 0.54 cm), and further evaluation showed no evidence of a hypercoagulable state. Upper-extremity venography was used to assess central venous patency and fully assess the venous vasculature. Unlike the widely patent venous systems seen in the abducted position, venography performed with the upper extremities in adduction showed marked narrowing of the brachial and/or axillary veins. The hemodynamic effects of this narrowing were readily apparent in patient 2 with the appearance of collateral filling of the cephalic vein in the adducted position. Patient 1 had a body mass index of 39 kg/m(2), and patient 2 had a body mass index of 34 kg/m(2). Each patient had excess axillary soft tissue that appeared to compress the venous outflow in adduction. To our knowledge, this is the first report to radiographically document soft-tissue compression of the venous outflow of the upper extremity in the adducted position, suggesting a mechanism whereby obesity, or at least excess axillary fat, can lead to premature hemodialysis vascular access failures.
ADUniversity of Nebraska Medical Center, Omaha, NE 68198-3040, USA. [email protected]

There we go, I was just looking for something. My intention wasn't that we should court disaster by messing with AVFs, it was more just that I was curious if there was any evidence that the logical but still theoretical concern had any evidence to back it up. There is also a HUGE amount of evidence regarding parachutes, mainly in the form of the case reports of all of those that failed. I know that the parachute comment is a common facetious one, but it does a disservice to the fact that many of the "obvious" comments like "do we need evidence that hypoxia causes death" are things that actually have a large amount of evidence (usually in the form of case reports) that actually do back them up. Whereas claims that are based purely on the "logic" of it in medicine also have a robust history of ultimately being disproven when finally investigated.

If there is one thing that all of medical education points to, and a career in medicine should reinforce, it's that you can't really take anything for granted in medicine, especially if it's based purely on the "logical" conclusion or opinion, leave absolute truths from opinions or "logical" conclusions to JCAHO.

Just to be clear, I am making a purely philosophical argument about the AVF business regarding beliefs and evidence.

 

[vector2]

There we go, I was just looking for something. My intention wasn't that we should court disaster by messing with AVFs, it was more just that I was curious if there was any evidence that the logical but still theoretical concern had any evidence to back it up. There is also a HUGE amount of evidence regarding parachutes, mainly in the form of the case reports of all of those that failed. I know that the parachute comment is a common facetious one, but it does a disservice to the fact that many of the "obvious" comments like "do we need evidence that hypoxia causes death" are things that actually have a large amount of evidence (usually in the form of case reports) that actually do back them up. Whereas claims that are based purely on the "logic" of it in medicine also have a robust history of ultimately being disproven when finally investigated.

If there is one thing that all of medical education points to, and a career in medicine should reinforce, it's that you can't really take anything for granted in medicine, especially if it's based purely on the "logical" conclusion or opinion, leave absolute truths from opinions or "logical" conclusions to JCAHO.

Just to be clear, I am making a purely philosophical argument about the AVF business regarding beliefs and evidence.

I know what you're trying to say but the treatment of AVFs is not some Rivers trial EGDT tale of caution where logical things like bumping the Hgb to 10 and starting inotropes for sepsis turned out to be useless.

Treating AVFs with kid gloves uses the same logic as not punching someone in the gut who has a 6.8cm AAA.

 

[caligas]

Fun to make fun of Clearsight etc, but they are a useful toy for occasional cases where you want continuous BP but don’t want to place or can’t easily place an art line.