Bilateral Mastectomy and Blood Pressure

[gpmedsec]

What is the current recommendation on taking blood pressure in the arm of a patient with bilateral mastectomies? Where is blood pressure taken on the leg?  TIA

[NRSKarenRN, BSN, RN]

Advice from Hosp. of Univ. of PA's Oncolink 2019

Blood pressures and IVs after mastectomy

Quote

Many organizations, like the American Cancer Society and the National Lymphedema Network, advise survivors to avoid blood pressure on the surgery side, if possible. However, there is not good research to support this recommendation and several studies have found it has no effect on arm swelling....

...The American Cancer Society and the National Lymphedema Network both recommend having blood pressure taken using a manual cuff and stethoscope. This avoids the high pressure squeezing that happens with a blood pressure machine, which often occurs a few times before giving a reading. Many organizations recommend using the thigh to take blood pressure. This requires a BP cuff that is large enough to wrap around the thigh in order to get an accurate reading. It is important to note that your thigh blood pressure should be taken lying down and that the upper number (systolic) is typically 10-40 mm Hg higher in the leg compared to the arm....

[MunoRN, RN]

My organization doesn't consider mastectomy to be a contraindication to using the upper arm for BP measurements.  

Keep in mind that this belief came about with no supporting evidence, or even particularly good rationale.  And even then it was in relation to lymph node removal, not mastectomy, although lymph nodes were commonly removed when a mastectomy was performed.  

There's no pathophysiological reason to believe BP measurements on the side where mastectomy and/or lymph node removal has occurred is likely to be harmful.  The concern was that this could cause lymphedema, although today a common treatment for lymphedema is 'pneumatic compression therapy', which involves placing a compression sleeve around the affected arm and having squeeze, much like a BP cuff.

Often it's not an issue, but there are certainly times when the inability to obtain accurate BP readings can be dangerous, either by causing unnecessary treatment or failing to provide needed treatment, in which case we educate as much as possible but ultimately the patient can refuse.

[macawake, MSN]

On 11/9/2020 at 2:15 AM, MunoRN said:

Keep in mind that this belief came about with no supporting evidence, or even particularly good rationale.  And even then it was in relation to lymph node removal, not mastectomy, although lymph nodes were commonly removed when a mastectomy was performed.  

There's no pathophysiological reason to believe BP measurements on the side where mastectomy and/or lymph node removal has occurred is likely to be harmful.  The concern was that this could cause lymphedema, although today a common treatment for lymphedema is 'pneumatic compression therapy', which involves placing a compression sleeve around the affected arm and having squeeze, much like a BP cuff.

I agree that there is no supporting evidence and that it’s axillary lymph mode removal, and not the mastectomy, that’s been thought of as a potential risk.

I don’t agree that the pressure a BP cuff creates is similar to pneumatic compression therapy. A standard sleeve worn on the arm to treat lymphedema is tighter distally than they are proximally in order to create a pressure gradient to help move lymph out of the arm.  

With pneumatic compression therapy the device is normally made up of several individual chambers which overlap like a compression bandage. It inflates in sequence from distal to proximal, then holds briefly before deflating. The the next cycle of sequential compression starts. Just as the sleeve made from fabric the aim is to move lymph from the arm. The pressures used to treat lymphedema are generally lower than the maximum pressure that a BP cuff is inflated to. 

Despite the lack of evidence of blood pressure cuffs posing a risk to patients who’ve had their axillary nodes removed, I choose the contralateral arm for blood pressure cuff placement if possible. Especially if the patient has also had radiation therapy on level l and ll axillary nodes. Patients often report that their ipsilateral arm feels ”weird”, or heavy or ”tingling”. They have also often been informed, not necessarily by medical professionals, to avoid having their blood pressure taken on the affected side. So, I explain the science to them but I see no reason to ”argue” the point when an alternative arm is available. 

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https://www.ncbi.nlm.nih.gov/pmc/articles/PMC7225495/

(Please note that the studies in the litterature review I linked in many cases are quite old. Both surgical techniques and radiotherapy techniques are constantly evolving. These days for example, at least in my part of the world and I suspect yours, we don’t habitually remove all axillary lymph nodes but instead do what’s called a ”sentinel node biopsy” and analyze that for disease before removing all level I and II nodes. Anecdotally, we’re seeing less arm morbidity these days than we previously did. (Anecdotally because I’m a bit lazy and don’t feel like looking for evidence right now)). 

OP, what are the guidelines at your place of employment? I think you need to find that out. Also looking at the research or rationale behind the facility’s guidelines is a good idea. My anecdotal data of how I do things shouldn’t be taken as medical advice.