Number of Lymph Nodes Removed?

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Specializes in Urgent Care, Oncology.

Hello all,

I am seeking information on limb usage policies after lymph nodes have been removed from the axillary area (biopsy, mastectomy, total removal). Does your institution have a policy on the number of lymph nodes in the arm? Meaning, is having 1 lymph node removed the same as 4 or 8?

I start IVs and perform venipunctures in an Oncology setting. When I started, I heard our policy was 4 or less from the arm. However, about 6 months ago I asked to see the policy in writing. Well, no one anywhere in the hospital could produce such a policy. So, now I am seeking to change that. I've obtained data from professional organizations and journal articles. So far, nothing seems to give a concrete number. I've reached out to the Breast Oncology surgeons to see what they tell the patients, but they haven't gotten back to me yet.

FYI I'm not putting this in Infusion or Oncology nursing because I'd like people to respond from all areas of expertise.

Thank you all for your responses.

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Great question. Kind of confusing though. Do you mean guidelines on starting the IV in the same arm the lymph nodes were removed from? One to four is okay, over four isn't?

If that is your question. I don't know the answer either.

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Specializes in Urgent Care, Oncology.
Do you mean guidelines on starting the IV in the same arm the lymph nodes were removed from? One to four is okay, over four isn't?

If that is your question. I don't know the answer either.

Yes, this is my question. If you've only had 1 removed, I'd understand your risk to be much lower than someone who has had 8. But, my question is what is the maximum number of lymph nodes that can be removed before it becomes too risky to use that upper extremity?

We are seeing not only breast patients (both male and female) but also a significant number of Cutaneous patients who have had axillary nodes removed.

The other issue that is also coming up is when both limbs have had nodes removed - typically it is one arm has had 1-2 removed and the other is 8+, but we do see some patients who have had (for example) 16 in one limb and 10 in the other removed. Typically we must obtain an order for a foot draw from the doctor in this instance. However, some of these patients are 20+ years out now, and from my understanding one's risk of developing lymphedema is highest in the first 5 years after removal. Furthermore, about half of out patients are going for radiology procedures, such as breast MRI or CT scans, and we are not allowed to start IVs in the foot since we are outpatient blood draw. Believe it or not, our outpatient facility also does not do IVs via ultrasound guided insertion; if we are unable to get an IV on a patient, we must send them to main campus. It it quite rare, typically only happens once every 6 to 8 weeks. However, many of these patients are also patients who are limited by limb, but it may be a false limitation due to the number of nodes removed.

Sorry that was such a long response. I hope that better defines my question. I greatly appreciate your response.

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Specializes in Adult and pediatric emergency and critical care.

We don't have a formal policy but generally we don't worry about seven or less, eight to thirteen are considered moderate risk, and more than thirteen are considered higher risk.

The risk of starting an IV in an arm with lymph node resection needs to be balanced against other individual risks and benefits. For example many patients will have lymph nodes removed from both axilla.

If we are giving more risky medications to patients who are at high risk for lymphedema we will have discussions with the medical and vascular access team about consideration for other access options.

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I worked out patient surgery so the IV was just LR, access for propofol, versed, anesthesia drugs, and the IV came out 4 - 8 hours later.

The surgeon in charge of the breast cancer clinic said a clean IV start in the affected arm wasn't a concern. But no mention of the number of lymph nodes removed.

And no documents or policy to share with you. :(.

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Specializes in Ambulatory Care-Family Medicine.

The surgeons in my area just tell patients which arm they can use for IVs, BPs, etc. Many patients have bilateral mastectomies and lymph node removals so we always just ask which arm their surgeon said could be used. I don't think we have a written policy for a specific number of lymph nodes though, just whichever arm the surgeon put on the chart to use for access.

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Specializes in Critical Care.

Our policy is that there are no limitations in terms of IV or BP on an arm with previous lymph node removal regardless of the number of nodes removed since there isn't sufficient evidence to support this. The theory that needle sticks or IV's should be avoided in arm after lymph node removal was conjecture by a surgeon in 1920, there has been no evidence support of this since. Similarly, the idea of avoiding constriction of the arm was conjecture originated in 1940, and has also not had good evidence to support it since.

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Specializes in Ambulatory Care-Family Medicine.
Our policy is that there are no limitations in terms of IV or BP on an arm with previous lymph node removal regardless of the number of nodes removed since there isn't sufficient evidence to support this. The theory that needle sticks or IV's should be avoided in arm after lymph node removal was conjecture by a surgeon in 1920, there has been no evidence support of this since. Similarly, the idea of avoiding constriction of the arm was conjecture originated in 1940, and has also not had good evidence to support it since.

Interesting. I'd love to bring this up to our policy review committtee to have them look into the evidence (or lack there of).

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