june1.11am.kotkiewicz · 2015-04-15 · nephrotic dysfunction goals of service 3. to provide...

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© 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


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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.


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Lymphedema Team

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Lymphedema Team

Incorporate CDT

Challenges

Advantages

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Lymphedema Team

Precautions Hemoglobin

Albumin

PlateletsPlatelets

Blood Urea Nitrogen (BUN)

Creatine

Brain Natriuretic Peptide (BNP)

Supplies

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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


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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


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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


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Breast Surgery Rehabilitation Group

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Edema Specific Protocols

ACTIVE TREATMENT

IVE

CA

RE

PA

LL

IAT

I


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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


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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


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Background:

Retroperitoneal sarcomas

Significant compression/compromiseg p p

Often, re-collateralization of the vasculature has already begun


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


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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)


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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


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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


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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”


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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


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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


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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


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Solutions

Solutions

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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


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Solutions

Solutions

Solutions


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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

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Solutions

• Swell spots to fabricated garments

• Elastic

• Wound care netting

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Solutions

Wounds or Weeping Edema

• Wound Care Service Consult?

• What is moisture level?

• Location?

Pain?• Pain?

• Goals of Care?

• Prognosis?


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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.


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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.


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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


june1.11am.kotkiewicz · 2015-04-15 · nephrotic dysfunction goals of service 3. to provide...

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