In an acute stroke patient, why should IV cannulation and blood pressure measurement not be performed on the paralysed limb, and what other conditions contraindicate using a limb for BP cuff or IV access?

Why IV Cannulation and BP Readings Should Not Be Performed on Paralyzed Limbs in Stroke Patients

In acute stroke patients, avoid IV cannulation and blood pressure measurement on the paralyzed limb primarily to preserve the unaffected limb for accurate neurological monitoring and to prevent complications from impaired sensation and circulation, though BP measurement itself is technically feasible on paralyzed limbs.

Rationale for Avoiding the Paralyzed Limb

IV Cannulation Concerns

• Impaired sensation in the paralyzed limb prevents the patient from reporting early signs of complications such as infiltration, extravasation, or phlebitis, which could lead to tissue damage going unnoticed 1

• Reduced mobility and muscle tone in paralyzed limbs increase the risk of venous stasis, potentially leading to thrombophlebitis or catheter-related complications 1

• The paralyzed limb should be preserved for neurological assessment, as frequent examination of motor function, sensation, and perfusion is critical for detecting early deterioration or hemorrhagic transformation 1

• Automatic blood pressure cuffs used with IV access in the same limb can cause hematoma formation, particularly in patients receiving thrombolytic therapy where even minor trauma should be avoided 1

Blood Pressure Measurement Considerations

• BP measurement is technically possible on paralyzed limbs because the cuff measures arterial wall compression and rebound, which remains intact regardless of motor function 2

• However, the non-paralyzed limb should be used preferentially to allow continuous monitoring of the affected limb for changes in perfusion, temperature, or swelling that might indicate complications 1

• In stroke patients receiving thrombolysis, BP cuffs should be rotated every 2 hours and checked frequently for petechiae, making the non-affected limb more practical for this intensive monitoring 1

Other Contraindications for BP Measurement and IV Cannulation

Absolute Contraindications for Both Procedures

• Limbs with active infection, cellulitis, or open wounds should be avoided due to risk of spreading infection or causing further tissue damage 1

• Limbs with arteriovenous fistulas or dialysis access must not be used for BP measurement or venipuncture, as this can damage the access or cause thrombosis 2

• Limbs with lymphedema should be avoided except in acute emergencies due to significantly increased risk of local infection and impaired fluid clearance 1, 3

• Limbs with recent vascular surgery, bypass grafts, or synthetic grafts are contraindicated due to risk of graft damage or thrombosis 1, 2

Specific Contraindications for IV Cannulation

• Limbs with severe peripheral vascular disease or absent pulses should be avoided as they have compromised circulation that increases risk of ischemia and tissue necrosis 1

• Areas with suspected or confirmed deep vein thrombosis are contraindicated due to risk of dislodging thrombus 1

• Limbs with coagulopathy or on anticoagulation require extra caution, and if used, sites should be easily compressible; avoid areas where bleeding cannot be controlled 1

• Sites near major trauma, fractures, or in proximity to main vascular axes should be avoided until vascular injury is excluded 1

Specific Contraindications for BP Measurement

• Do not place cuffs directly over arteriovenous malformations or vascular bruits, as compression can damage vessels or cause thrombosis 2

• Avoid measurement immediately after arterial puncture or interventional procedures in that limb for at least 24 hours to prevent hematoma formation 1

• Limbs with subclavian or innominate artery stenosis (suggested by inter-arm BP difference >15-20 mmHg) will give inaccurate readings 2

Practical Clinical Algorithm

For Acute Stroke Patients:

1. Use the non-paralyzed limb as first choice for both IV access and BP monitoring 1

2. If bilateral upper extremity issues exist, measure BP in the thighs or legs using appropriate cuff size in supine position (noting that lower limb systolic BP is physiologically 20-30 mmHg higher) 2

3. In patients receiving thrombolysis, avoid all invasive procedures including arterial punctures, catheter insertions, and nasogastric tubes for the first 24 hours 1

4. If peripheral access is impossible, central venous catheter placement may be considered as a safe alternative even in thrombolysis candidates 4

5. Monitor the paralyzed limb continuously for perfusion, temperature, and swelling rather than using it for procedures 1

Common Pitfalls to Avoid:

• Do not use automatic BP cuffs on limbs with IV access receiving thrombolytics, as this significantly increases hematoma risk; if necessary, check the cuff site frequently and discontinue if petechiae appear 1

• Never assume a limb is suitable without checking for lymphedema, vascular access, or recent surgery, as these are frequently overlooked contraindications 1, 3

• Do not rely on veins that require continuous tourniquet application to remain patent, as this indicates inadequate vascular access requiring evaluation 3, 5