content_175.pdf

Purpose & Patient Population

TYPES OF PATIENTS ADDRESSED: Sample not described

Type of Resource/Evidence-Based Process

PROCESS OF DEVELOPMENT: Study utilized previous Cochrane Systematic reviews along with current references to a United Kingdom national consensus on standards of practice for people at-risk for, or who have, lymphedema (LE)

Evidence weighed using the following classification:

A = Clear research evidence
B = Limited supporting research evidence
C = Experienced common sense judgment.

Guidelines & Recommendations

Recommended for Practice

Complete decongestive therapy

Patients with LE should receive a coordinated package of care appropriate to their needs (B).

Compression bandaging

Multilayer inelastic lymphedema bandaging (B)
Compression garments (C)

Management of infection: Cellulitis/erysipelas

Criteria for hospitalization
- Signs of septicemia (e.g., high fever, hypotension, tachycardia, confusion, vomiting).
- Continuing or deteriorating systemic signs with or without deteriorating local signs after 48 hours of antibiotic therapy.
- Unresolved or deteriorating local signs with or without systemic signs after first- and second-line oral antibiotics.
- Close medical follow-up

Exclude other causes of systemic infection, DVT, or dermatologic conditions such as eczema and contact dermatitis.

Before starting antibiotics
- Swab any exudates, if present
- Mark extent of rash and date edge
- Note any painful or swollen regional lymph nodes
- Obtain labs for ESR, CRP, WBC, and blood cultures.

Begin antibiotics as soon as possible (recommended for practice).

During bed rest, elevate limb, administer appropriate analgesia, and increase fluid intake.

Avoid simple lymphatic drainage (SLD) and manual lymphatic drainage (MLD). If tolerated, continue compression at a reduced level or switch from compression garments to MLLB.

Avoid long periods without compression.

Likely to be Effective

Manual lymphatic drainage (C)

Prevention of infection: skin care

Good skin care regimens should be implemented by patients and caregivers in the management of LE (B).
Use neutral pH soaps to avoid drying.
Apply emollients.
Keep skin folds clean and dry.
Inspect skin for cuts, scrapes, abrasions, and insect bites.
Avoid scented products.

Benefits Balanced With Harm

Exercise

Exercise/movement/elevation (C)
Breathing exercises (C)

Prophylactic antibiotics: prevention of infection

Patients are advised to travel with a two-week supply of antibiotics if they have a history of lymphedema.

Effectiveness not Established

Intermittent pneumatic compression (C)

Simple lymphatic drainage (SLD)

Surgery (limited evidence, carefully selected patients may benefit, more research needed)

Surgical reduction
Bypass of lymphatic obstruction
Liposuction/lipectomy

Expert Opinion

Patient education

People at risk of lymphedema should be identified early during routine assessment, monitored, and taught self-care (C).
Patients and caregivers should be offered information about LE and its management.
- Take good care of skin and nails.
- Maintain optimal body weight (B).
- Eat a balanced diet.
- Avoid tight clothing, watches, and jewelry.
- Avoid extremes in temperature.
- Use sunscreen and insect repellent.
- Wear compression garments if prescribed.
- Undertake exercise and diaphragmatic breathing exercises.
- Wear comfortable, supportive shoes.
Risk factors for upper extremity lymphedema
- Surgery of breast with axillary node dissection
- Scar formation, radiodermatitis from postoperative radiotherapy
- Radiotherapy to breast
- Drainage or wound complications
- Cording or seroma formation
- Obesity
- Congenital predisposition
- Trauma to affected extremity (venipuncture, injection, BP)
- Taxane chemotherapy
- Insertion of a pacemaker
- AV fistula for dialysis
- Living in or visiting a lymphatic filariasis endemic area
Risk factors for lower extremity lymphedema
- Inguinal node dissection
- Postoperative pelvic radiotherapy
- Recurrent soft-tissue infection
- Obesity
- Vein stripping or vein harvesting
- Genetic predisposition
- Intrapelvic or intra-abdominal tumor
- Thrombophlebitis
- Poor nutritional status
- Chronic skin disorders or inflammation
- Any unresolved asymmetric edema
- Concurrent illness
- Immobilization or prolonged limb dependency
- Living in or visiting a lymphatic filariasis endemic area

Measurement

Accurate assessment including staging (C)
- Measurement of LE
- Assessment of skin
- Assessment of vascular integrity
Patients with LE should receive psychological screening to identify those who require help to cope with the condition and those who require specialist intervention (C).