Lymphedema results from disruption or obstruction of lymphatic drainage, leading to interstitial fluid accumulation, tissue fibrosis, and increased susceptibility to infection. Anesthesia considerations for patients at risk for lymphedema require an understanding of lymphatic physiology, the underlying causes of lymphatic impairment, and the potential perioperative factors that may exacerbate fluid accumulation. Patients at risk include those with a history of lymph node dissection, radiation therapy, malignancy, trauma, or congenital lymphatic disorders. Perioperative management should aim to minimize additional lymphatic injury while ensuring safe and effective anesthesia care.
Anesthesia care begins with a preoperative evaluation that facilitates the identification of patients who have established lymphedema or are at increased risk due to prior surgical or oncologic treatment, most frequently involving the axillary or inguinal lymph nodes. A detailed history should include the extent of lymph node removal, radiation exposure, prior episodes of cellulitis, and current lymphedema severity, as appropriate. Physical examination helps document baseline limb size, skin integrity, and signs of infection. Patients should be counseled regarding perioperative strategies to reduce exacerbation. Additionally, collaboration with surgical and nursing teams is important to ensure consistent preventive measures throughout the perioperative period.
Vascular access and monitoring require particular attention in this population. Whenever possible, intravenous cannulation, blood pressure measurement, and arterial line placement should be avoided in limbs at risk for lymphedema, as mechanical compression, venipuncture, and tissue trauma may impair lymphatic flow and increase the likelihood of swelling or infection. Alternative sites, including the contralateral limb or lower extremities, may be used when clinically appropriate. In cases where no alternative exists, careful technique and minimization of repeated trauma are essential, along with close postoperative monitoring for complications.
Intraoperative fluid management plays a role in minimizing lymphedema exacerbation. Excessive intravenous fluid administration may increase interstitial fluid accumulation, particularly in patients with compromised lymphatic drainage. A goal-directed approach to fluid therapy, guided by patient comorbidities and surgical factors, helps maintain adequate intravascular volume without contributing to tissue edema. Anesthetic agents and techniques should be selected based on overall patient status, as no specific anesthetic drugs have been shown to directly worsen lymphedema. However, regional anesthesia techniques involving the at-risk limb should be carefully considered in this patient population, as needle trauma and local anesthetic volume may theoretically affect lymphatic flow and lyphedema risk, though evidence remains limited.
Positioning and intraoperative care are also important in preventing lymphatic compromise. Prolonged dependent positioning, excessive pressure from arm boards, straps, or surgical equipment, and inadequate padding can all contribute to impaired lymphatic and venous return. Proper positioning with neutral alignment and adequate support reduces the risk of postoperative swelling. Normothermia should be maintained, as hypothermia-induced vasoconstriction may impair lymphatic drainage.
Postoperative management focuses on early recognition and prevention of lymphedema exacerbation. Pain control that facilitates early mobilization is beneficial, as muscle activity supports lymphatic flow. Patients should be monitored for limb swelling, skin changes, and signs of infection, particularly cellulitis, which can worsen lymphatic dysfunction. Communication with postoperative care teams ensures that limb precautions are continued beyond the operating room, including avoidance of unnecessary venipuncture or compression.
Anesthesia care for patients at risk for lymphedema requires a proactive approach. By identifying at-risk individuals, minimizing trauma and compression to vulnerable limbs, optimizing fluid management, and maintaining vigilant postoperative monitoring, anesthesiologists can reduce the likelihood of lymphedema exacerbation while providing safe and effective perioperative care.