Why can't blood pressures be taken on the side of a lumpectomy (surgical removal of a breast lump) or mastectomy (surgical removal of one or both breasts)?

Why Blood Pressure Measurements Should Not Be Taken on the Side of a Lumpectomy or Mastectomy

Blood pressure measurements should not be taken on the arm ipsilateral to a lumpectomy or mastectomy due to the risk of lymphedema and other complications that can significantly impact morbidity and quality of life.

Physiological Rationale

The primary reason for avoiding blood pressure measurements on the affected side relates to disruption of the lymphatic system:

• During lumpectomy or mastectomy procedures, particularly those involving axillary lymph node dissection, the lymphatic drainage system of the arm is compromised
• The pressure from a blood pressure cuff can:
  • Impede already compromised lymphatic flow
  • Potentially cause trauma to lymphatic vessels
  • Increase the risk of lymphedema development or exacerbation

Clinical Evidence and Guidelines

Current perioperative guidelines support careful consideration of blood pressure monitoring sites in patients who have undergone breast cancer surgery:

• The British Journal of Anaesthesia perioperative quality initiative consensus statement emphasizes the importance of appropriate arterial pressure monitoring sites 1
• Continuous monitoring is recommended for high-risk procedures, but the site selection must account for patient-specific factors, including previous surgeries 1
• Guidelines highlight that proper measurement techniques should include "ensuring appropriate cuff size for each arm" and "positioning both arms at heart level" 2

Risks Associated with BP Measurement on the Affected Side

1. Lymphedema development:

   • Compression from the blood pressure cuff can trigger or worsen lymphedema in the affected arm
   • Once developed, lymphedema is often chronic and difficult to manage

2. Infection risk:

   • Compromised lymphatic drainage increases susceptibility to infection
   • Even minor trauma from needle punctures or blood pressure cuffs can introduce pathogens 3

3. Pain and discomfort:

   • Post-surgical sensitivity in the affected arm can make blood pressure measurements uncomfortable
   • Breast cancer survivors report significant rates of chronic pain following surgery 4

Alternative Approaches

When caring for patients with history of lumpectomy or mastectomy:

• Use the contralateral arm for all blood pressure measurements
• If bilateral mastectomy/lumpectomy has been performed, consider:
  • Lower extremity blood pressure measurements
  • Non-invasive continuous monitoring technologies that don't require cuff inflation
  • In high-risk surgical cases requiring continuous monitoring, arterial line placement in a lower extremity 1

Special Considerations

• The risk persists long-term after surgery, not just in the immediate post-operative period
• The risk is higher in patients who have undergone axillary lymph node dissection compared to sentinel lymph node biopsy
• A Swedish study indicated that when proper aseptic technique is used, the risk of complications from blood draws may be lower than traditionally thought, but this doesn't necessarily extend to the repetitive compression from blood pressure cuffs 3

Clinical Recommendation

Always avoid taking blood pressure measurements on the arm ipsilateral to a lumpectomy or mastectomy, especially if axillary lymph node dissection was performed, to prevent lymphedema and associated complications that can significantly impact quality of life.

This practice should be maintained indefinitely following surgery, as the risk of lymphedema development can persist for years after the initial procedure.