Upload
others
View
2
Download
0
Embed Size (px)
Citation preview
5/14/2013
1
© 2013 Memorial Sloan-Kettering Cancer Center, All Rights Reserved.
This presenter has no conflict of interest to report regarding any commercial epo t ega d g a y co e c a
product/manufacturer that may be referenced during this presentation
Objectives
Discuss Complete Decongestive Therapy (CDT) treatment for lymphedema inpatients
Briefly discuss educational resources MSK provides to patients at risk for lymphedema
Explain how lymphedema concepts and techniques have been utilized, modified, and applied to assist with goals of care for patients with various diagnoses
Review goals and guidelines for each of these approaches
Examine common challenges
© 2013 Memorial Sloan-Kettering Cancer Center, All Rights Reserved.
5/14/2013
2
Goals of Service
1. Provide effective CDT to patients referred with lymphedema
2. Facilitate achievement of plan of care goals for patients with other diagnosis such as: Renal insufficiency Renal insufficiency
Capillary leak syndrome
Hypoalbuminemia
Amyloidosis Autonomic instability
Nephrotic dysfunction
Goals of Service
3. To provide effective treatment for patients with planned large vessel removal/ligation (Inferior
S )
4. To provide education to at-risk populations via:
Lower extremity vena cava, Sarcoma) utilizing a team approach to pre-operative garment fitting and follow-up
lymphedema prevention group
Breast surgery rehabilitation group (BSRG)
International Society of Lymphology (ISL) Lymphoedema Staging1
Stage 0
• A subclinical state where swelling is not evident despite impaired lymph transport. This stage may exist for months or years before edema becomes evident.
Stage I
• This represents early onset of the condition where there is accumulation of tissue fluid that subsides with limb elevation. The edema may be pitting at this stage.
Stage II
• Limb elevation alone rarely reduces swelling and pitting is manifest.
Late Stage II
• There may or may not be pitting as tissue fibrosis is more evident.
Stage III
• The tissue is hard (fibrotic) and pitting is absent. Skin changes such as thickening, hyperpigmentation, increased skin folds, fat deposits and warty overgrowths develop.
© 2013 Memorial Sloan-Kettering Cancer Center, All Rights Reserved.
5/14/2013
3
Lymphedema Team
MS
KC
C p
ho
tos
Lymphedema Team
Incorporate CDT
Challenges
Advantages
MS
KC
C p
ho
tos
Lymphedema Team
Precautions Hemoglobin
Albumin
PlateletsPlatelets
Blood Urea Nitrogen (BUN)
Creatine
Brain Natriuretic Peptide (BNP)
Supplies
MS
KC
C p
ho
tos
© 2013 Memorial Sloan-Kettering Cancer Center, All Rights Reserved.
5/14/2013
4
Educational Programs at Memorial Sloan-Kettering Cancer Center
Lower Extremity Lymphedema Prevention Group
Breast Surgery Rehabilitation Group
Evidence Based Education
Preventative Measures for Lymphedema: Separating Fact from Fiction2
Evidence Supporting
Strong: Participation in a supervised
exercise regimen both in patients with lymphedema
Limited: Venipuncture should be
avoided in patients with a history of lymph node
and in those at risk for developing lymphedema
Good: Maintaining normal body
weight or avoiding weight gain in patients who are at risk for developing lymphedema
y y psurgery
Preventative measures regarding limb constriction, elevation, heat and cold, and air travel and use of compression garments when flying
© 2013 Memorial Sloan-Kettering Cancer Center, All Rights Reserved.
5/14/2013
5
Summary of Evidence2
Risk Factors-Greater body weight
-Higher BMI
-Infection or injury in the ipsilateral arm since surgery
Ed ti Education-All patients should be educated about lymphedema based on the individual risk associated with the surgical procedure, not the amount of nodes removed
Resistance Training3
-No limit on the resistance level (gradual /progressive)
-Not contraindicated
MSKCC Axillary Procedure Guidelines4-13
Objective-To guide clinical practice and patient education on lymphedema risk associated with upper extremity axillary surgery
Strength of Evidence-Level A (randomized controlled trial/meta-analysis)
4-13
© 2013 Memorial Sloan-Kettering Cancer Center, All Rights Reserved.
5/14/2013
6
Summary of Evidence4-13
Arm Morbidity-SLNB <ALND
Quality of Life-SLNB>ALND
Increased Risk of Lymphedema?
-(+) MastectomyLarger Extent of ALND
-(+) XRT SLNB
-No correlation between # of nodes removed and change in UE circumference or incidence of lymphedema
( )-Presence of (+) axillary nodesWho Develops
Lymphedema?-SLNB 0-7%-ALND 15-25%
How We Teach
LE Lymphedema Prevention Group
• This program is appropriate for patients who have undergone a pelvic lymph node sampling/dissection
• We review:Differences Between Edema and Lymphedema– Differences Between Edema and Lymphedema
– Risk Factors
– Early signs of Lymphedema
– Exercise Guidelines
– Compression
– Skin Care
– Precautions
© 2013 Memorial Sloan-Kettering Cancer Center, All Rights Reserved.
5/14/2013
7
Breast Surgery Rehabilitation Group
MS
KC
C p
ho
tos
Edema Specific Protocols
ACTIVE TREATMENT
IVE
CA
RE
PA
LL
IAT
I
© 2013 Memorial Sloan-Kettering Cancer Center, All Rights Reserved.
5/14/2013
8
Referral Criteria
Patients with SYMPTOMATIC autonomic and nephrotic dysfunction in the setting of amyloidosis WITH OR WITHOUT THE PRESENCE OF EDEMA
Nephrotic range proteinuria (>3gm/24hours)
Urine output > or equal to 150cc/day Urine output > or equal to 150cc/day
Patients with hypoalbuminemia (< or equal to 3.5g/dl serum albumin)
Patients with decreased fluid mobilization as determined by the primary medical team
Referral Criteria
Patients with volume overload or capillary leak syndrome
Patients with SYMPTOMATIC orthostatic h t ihypotension
Patients potentially avoiding dialysis intervention
Intact cognition, communication, and sensation
Medically stable to participate in compressive therapy sessions
Exclusion Criteria
Anuric (<150cc urine/day)
Impaired cognition, communication, or sensation
Cellulitis, arterial ulcerations, moderate to severe PVD as documented by ankle brachial index (ABI), and skin macerations
Not medically stable to participate in compressive therapy sessions
© 2013 Memorial Sloan-Kettering Cancer Center, All Rights Reserved.
5/14/2013
9
Considerations of Rehabilitation Parameters
Standard lymphedema precautions and contraindications DO NOT NECESSARILY apply
Hematologic, renal, and cardiac functions ARE NOT NECESSARILY contraindications forNOT NECESSARILY contraindications for bandaging
Sound clinical judgment on a case-by-case basis
Communication with physician critical
Bandaging Guidelines
Patient comfort and adaptation
The highest level of compression tolerated is ideal, 20-30mmHgis ideal, 20 30mmHg
Placement?
Progressed to a 24-hour wearing schedule
Large Vessel Resection/Ligation
© 2013 Memorial Sloan-Kettering Cancer Center, All Rights Reserved.
5/14/2013
10
Large Vessel Resection/Ligation
Background:
Retroperitoneal sarcomas
Significant compression/compromiseg p p
Often, re-collateralization of the vasculature has already begun
Large Vessel Resection/Ligation
Referral Criteria: Large vessel
ligation/resection
Sarcoma with or
Our Role: Pre-operative
measurements
Post-op edema service without LND or biopsy
Melanoma with or without LND or biopsy
pconsult for bandaging and MLD
Referral for outpatient therapy
Measuring for Compression Stockings
Measure widest thigh
Measure widest calf
Measure smallest circumference proximal to malleoli
Please circle patient’s size and write script accordingly for Juzo or Jobst garments. Contact Jean Kotkiewicz, [email protected] or Ron Lee, [email protected] with questions.
Patient Name: MRN: Thigh Calf Ankle
Kotkiewicz, [email protected] or Ron Lee, [email protected] with questions.
JOBST size chart for 15-20, 20-30, and 30-40mmHg compression stockings
SIZE ANKLE CALF THIGH S 18-21cm 28-38cm 40-62cm M 21-25cm 30-42cm 46-70cm L 25-29cm 32-46cm 54-78cm XL 29-33cm 34-50cm 60-81cm
JUZO size chart for 20-30 and 30-40mmHg compression stockings
SIZE ANKLE CALF THIGH I 18-21cm 29-38cm 41-60cm II 21-24cm 34-43cm 50-68cm III 24-27cm 37-49cm 54-75cm IV 27-31cm 41-53cm 57-79cm V 31-35cm 46-58cm 62-85cm
© 2013 Memorial Sloan-Kettering Cancer Center, All Rights Reserved.
5/14/2013
11
Large Vessel Resection/Ligation
Objective Measures to
Determine Improvement:
Patient Adherence With Schedule
Maintenance of Measurements at Follow Up
Long-Term Garment Use
Amyloidosis
Amyloidosis
Background: Extracellular deposition of amyloid in one or more
organs: Heart, Kidneys, Nervous System, Liver, Soft Tissue
Chemotherapy and Stem-Cell TransplantChemotherapy and Stem Cell Transplant
Nephrotic Dysfunction15
Proteinuria– Lose protein through urine
– Brain Natriuretic Peptide (BNP)
© 2013 Memorial Sloan-Kettering Cancer Center, All Rights Reserved.
5/14/2013
12
Amyloidosis – Our RoleDecreased Cardiac Output16
AutonomicInstability16
Impaired Vascular Tone16
Baroreceptor Dysfunction
Orthostatic Hypotension
Decreased Function
INCREASED FUNCTION
EXTERNAL COMPRESSION
Cardiac Amyloidosis 17
Amyloidosis - Our Role
ADD EXTERNAL
COMPRESSION
ASSIST WITH FORWARD FLOW TO
PATIENT WILL EFFECTIVELY
DIURESE
HIGHBNP /CREATININE
RIGHT SIDE OF HEART
LEFT SIDE OF HEART WILL
FILLKIDNEYS ADEQUATELY
PERFUSE
DIURESE
© 2013 Memorial Sloan-Kettering Cancer Center, All Rights Reserved.
5/14/2013
13
AmyloidosisObjective Measures to Determine
Improvement:
Weight
Circumferential Urine Production
Circumferential Measurements
Orthostatic Changes
Creatinine
BNP
Kidney Function
Albumin
Tolerance of Therapies
Renal Insufficiency
Renal Insufficiency18
Background: Decreased Blood Flow to the Kidneys
Decreased Perfusion
Limits a Patient’s Ability to Respond to the Use of DiureticsDiuretics
Defined by the Presence of: Heavy Proteinuria (Protein Excretion Greater Than
3.5 g/24 Hours)
Hypoalbuminemia (Less Than 3.0 g/dL)
Peripheral Edema
© 2013 Memorial Sloan-Kettering Cancer Center, All Rights Reserved.
5/14/2013
14
Renal Insufficiency – Our Role
Decreased Blood Flow to Kidneys
Decreased Perfusion
CAD?Renal Failure?
Not Responding to Diuretics Need Dialysis
EXTERNAL COMPRESSION
INCREASED PRE-LOAD AND PERFUSION
DIURETICS WORK, NO DIALYSIS
Renal Insufficiency
Objective Measures to Determine Improvement: Stabilized Blood Pressure
Decrease in Weight
Decrease in Creatinine
Decrease in BUN
Overall Improvement in Kidney Function Acceptable Urine Output
Example: Orders Received
AMYLOID• Transfusion dependent
Myelodysplastic Syndrome (MDS)
RENAL INSUFFICIENCY• Cannot Diurese
• Kidneys Suffer
• No Intravascular Fluid• Allogenic Transplant
• Iron Overload
• Liver Dysfunction
• Restrictive Cardiomyopathy
No Intravascular Fluid
• Low Albumin
• No “forward flow”
© 2013 Memorial Sloan-Kettering Cancer Center, All Rights Reserved.
5/14/2013
15
Capillary Leak Syndrome
Capillary Leak Syndrome
Growth Factors
Very Rare
Change in Capillary Wall Pressure
Very Rare
Sudden Drop in Blood Pressure
No Known Cause
**Watch Platelets**
Multifactorial Edema
© 2013 Memorial Sloan-Kettering Cancer Center, All Rights Reserved.
5/14/2013
16
Multifactorial EdemaDecreased Functional Participation? Extensive Surgery?
Low Albumin19?
Non-Specific EdemaNon-Specific Edema
We are able to assist with goals of care and edema reduction using appropriate CDT techniques?
Increased Functional Ability / Decreased Discomfort
Case Study
Case Study
Mr. S
-Diagnosis?
-Medical History?
-Treatment?-Treatment?
-Referred for physical and occupational therapy
-Lymphedema service consulted
© 2013 Memorial Sloan-Kettering Cancer Center, All Rights Reserved.
5/14/2013
17
MS
KC
C p
ho
tos
MS
KC
C p
ho
tos
M
© 2013 Memorial Sloan-Kettering Cancer Center, All Rights Reserved.
5/14/2013
18
Most Common Inpatient Lymphedema/Edema
Challenges?Challenges?
Scrotal Edema/ Lymphedema
Difficult to bandage in real life• Slides off with movement
• Risk of tourniquet
I d ti• Increased time
• Patient cannot duplicate
• Decreased compliance after urination
• Easily soiled
• Moisture levels
• Skin integrity
© 2013 Memorial Sloan-Kettering Cancer Center, All Rights Reserved.
5/14/2013
19
Solutions
Solutions
MS
KC
C p
ho
tos
MS
KC
C p
ho
tos
Labia Edema/ Lymphedema
Not possible to bandage in real life Difficult area in general
Easily soiled
Moisture levelsMoisture levels
May slide with movement
Decreased compliance after urination
Skin integrity
Abdominal compression may not be tolerated
© 2013 Memorial Sloan-Kettering Cancer Center, All Rights Reserved.
5/14/2013
20
Solutions
Solutions
Solutions
© 2013 Memorial Sloan-Kettering Cancer Center, All Rights Reserved.
5/14/2013
21
Hard to Treat Areas
• Chest
• Head
• Neck
Chin
• Dorsum of Foot
• Dorsum of Hand
• Brachioradialis
Lateral Thigh• Chin
• Side of Breast
• Side of Abdomen
• Lateral Thigh
• Side of Trunk
• Under Eye Area
Solutions• Swell Spots/ Foam
Chips
• Be Creative
• Add to any Area
• Cut / Modify
• Sew to Garment for More Security
Head and Neck Lymphedema
MS
KC
C p
ho
tos
MS
KC
C p
ho
tos
© 2013 Memorial Sloan-Kettering Cancer Center, All Rights Reserved.
5/14/2013
22
Solutions
• Swell spots to fabricated garments
• Elastic
• Wound care netting
MS
KC
C p
ho
tos
Solutions
Wounds or Weeping Edema
• Wound Care Service Consult?
• What is moisture level?
• Location?
Pain?• Pain?
• Goals of Care?
• Prognosis?
© 2013 Memorial Sloan-Kettering Cancer Center, All Rights Reserved.
5/14/2013
23
Solutions - Define It First
Arterial
• Punched out lesion
• DRY
• Usually lateral leg
Venous
• Irregular borders
• WET, increased drainage
• Usually medial legUsually lateral leg
• NO COMPRESSION
Hydrocolloid
Usually medial leg
• ONLY COMPRESS BASED ON ABI SCALE20-21
Alginate
Review of Objectives
Discuss CDT treatment for lymphedema inpatients
Briefly discuss educational resources MSKCC provides to patients at risk for lymphedema
Explain how lymphedema concepts and techniques have p y p p qbeen utilized, modified, and applied to assist with goals of care for patients with various diagnoses
Review goals and guidelines for each of these approaches
Examine common challenges
References1. International Society of Lympheodema Staging. Best Practice for the Management of
Lymphoedema; MEP Ltd, 2006.
2. Yeliz C, Pusic A, Mehrara B. Preventative Measures for Lymphedema: Seperating fact from Fiction. J AM Coll Surg. 2011.
3. Lee, T., et al., Factors That Affect Intention to Avoid Strenuous Arm Activity After Breast Cancer Surgery. Oncology Nursing Forum, 2009. 36(4): p. 454-462.
4. Baron, R., et al., Eighteen Sensations After Breast Cancer Surgery: A 5-year Comparison of Sentinel Lymph Node Biopsy and Axillary Lymph Node Dissection. Annals of Surgical Oncology, 2007. 14(5): p. 1653-1661.
5. Goldberg, J., et al., Morbidity of Sentinel Node Biopsy in Breast Cancer: The Relationship Between the Number of Excised Lymph Nodes and Lymphedema. Annals of Surgical Oncology, 2010. Published online.
6. Lucci, A., et al., Surgical Complications Associated with SLND Plus ALND Compared with SLND Alone in the American College of Surgeons Oncology Group Trial Z0011. J Clin Oncol, 2007. 25: p. 3657-3663.
© 2013 Memorial Sloan-Kettering Cancer Center, All Rights Reserved.
5/14/2013
24
References
7. Schmitz, K., et al., Weight Lifting in Women with Breast Cancer-Related Lymphedema. New Eng J Med, 2009. 361(7): p. 664-73.
8. Sclafani, L., et al., Sentinel Lymph Node Biopsy and Axillary Dissection: Added Morbidity of the Arm, Shoulder and Chest Wall After Mastectomy and Reconstruction. The Cancer Journal, 2008. 14(4): p. 216-222.
9. Tsai, J., et al., The Risk of Developing Arm Lymphedema Among Breast Cancer Survivors: A Meta-Analysis of Treatment Factors. Ann Surg Oncol, 2009. 16: p. 1959-1972.
10. Mansel, R., et al., Randomized Multicenter Trial of Sentinel Node Biopsy Versus Standard Axillary Treatment in Operable Cancer: The ALMANAC Trial. J Nat Cancer Institute, 2006. 98(9): p. 599-609.
11. McLaughlin, S., et al., Prevalence of Lymphedema in Women With Breast Cancer 5 Years After Sentinel Lymph Node Biopsy or Axillary Dissection: Objective Measurements. J Clin Oncol, 2008. 26(32): p. 5213-5219.
12. McLaughlin, S., et al., Prevalence of Lymphedema in Women With Breast Cancer 5 Years After Sentinel Lymph Node Biopsy or Axillary Dissection: Patient Perceptions and Precautionary Behaviors. J Clin Oncol, 2008. 26(32): p. 5220-5226.
References14. Poage, E., et al., Demystifying Lymphedema: Development of the Putting Evidence Into Practice Card.
Clin J Onc Nurs, 2008. 12(6): p. 951-964.
15. Leung, Nelson; Appel, Gerald; Kyle, Robert. Renal Amyloidosis. Up to Date. Last literature review version 19.2 May 2011.
16. Gorevic, Peter D. Treatment of Secondary (AA) Amyloidosis. Up to Date. Last literature review version 19.2 May 2011.
17. Falk, Rodney H.,M.D. [[email protected]]Falk, R. Amyloid Heart Disease. Progress in Cardiovascular Diseases 2010;52:347-361.
18. Burton, Rose. Mechanism and treatment of edema in nephrotic syndrome. Up to Date. Last literature review version 19.2 May 2011.
19. Henry JA, et al. Assessment of hypoproteinaemic oedema: a simple physical sign. Br Med J 1978;890.
20. Hunter, Susan. Compression therapy for venous ulcers. Advances in skin and wound care. 2005;18:(8):404-408.
21. MacKinnon J. Doppler ultrasound assessment in peripheral vascular disease. Up to Date. 2009.http://ptjournal.apta.org. Accessed January 2011.
Resources
• Beck, L. Functional Outcomes and Quality of Life after Tumor-Related Hemipelvectomy. Physical Therapy August 2008 vol. 88 no. 8 916-927.
• Burton, Rose. Pathophysiology and etiology of edema in adults. Up to Date. Last literature review version 19.2 May 2011.
• Emile R Mohler, III, MD Lymphedema: Etiology, clinical manifestations, and diagnosis. http://www.uptodate.com/home/index.html. October, 2011.
• Eyre R Evaluation of the Acute Scrotum in AdultsEyre, R. Evaluation of the Acute Scrotum in Adults. http://www.uptodate.com/home/index.html. August, 2011.
• Foldi M, Foldi E. Foldi’s Textbook of Lymphology for Physicians and Lymphedema Therapists. Maryland Heights, MO
• Mosby Elsevier; 2006.Fu, Mei R. Cancer Survivors’ views of lymphedema management. Journal of Lymphoedema. 2010;5:(2):39–48.
• Garaffa Giulio. The management of genital lymphedema. BJUI. 2008;102:480-484.
© 2013 Memorial Sloan-Kettering Cancer Center, All Rights Reserved.
5/14/2013
25
Resources
• Gestring M. Negative Pressure Wound Therapy. http://www.uptodate.com/home/index.html. February, 2011.
• Johnson S. Compression hosiery in the prevention and treatment. J Tissue Viability. 2002;12:(2):67.
• Lawenda, Brian D. Lymphedema: A primer on the Identification and Management of a Chronic Condition in Oncologic Treatment. CA 2009;55:(1).
• Mansel R et al Randomized Multicenter Trial of Sentinel Node Biopsy Versus StandardMansel, R., et al., Randomized Multicenter Trial of Sentinel Node Biopsy Versus Standard Axillary Treatment in Operable Cancer: The ALMANAC Trial. J Nat Cancer Institute, 2006. 98(9): p. 599-609.
• McGee SR. Physical examination of venous pressure: a critical review. Am Heart J. 1998;136:10-18.
• Rockson SG. Lymphedema. AM J Med. 2001;110:288-295.
• Rose BD. General principles of the treatment of edema in adults. http://www. uptodate.com/home/index.html. June, 2010.
Resources
• Sapira JD. The Art and Science of Bedside Diagnosis. Williams & Wilkins, Baltimore, 1990.
• Stephens, Thomas. Compression in the treatment of venous leg ulcers. Up To Date.1997.
• Tsai, J., et al., The Risk of Developing Arm Lymphedema Among Breast Cancer Survivors: A Meta-Analysis of Treatment Factors. Ann Surg Oncol, 2009. 16: p. 1959-1972.
• Whitaker,J. Genital Oedema. J Lymphoedema. Vol 4;1:2009.
• www.lympho.org/resources.php
ld id d• www.worldwidewounds.com
• Zuther, J. Lymphedema Management: The Comprehensive Guide for Practitioners. 2nd ed. New York, NY: Thieme Publishing Group; 2009.
QUESTIONS?
Thank you
© 2013 Memorial Sloan-Kettering Cancer Center, All Rights Reserved.