lymphangiogram

Lymphangiography

Common use

Area of application

Contrast

Description

This procedure is contraindicated for

• high alert Patients who are pregnant or suspected of being pregnant, unless the potential benefits of a procedure using radiation far outweigh the risk of radiation exposure to the fetus and mother.
• high alert Patients with conditions associated with adverse reactions to contrast medium (e.g., asthma, food allergies, or allergy to contrast medium). Although patients are still asked specifically if they have a known allergy to iodine or shellfish, it has been well established that the reaction is not to iodine, in fact an actual iodine allergy would be very problematic because iodine is required for the production of thyroid hormones. In the case of shellfish, the reaction is to a muscle protein called tropomyosin; in the case of iodinated contrast medium, the reaction is to the noniodinated part of the contrast molecule. Patients with a known hypersensitivity to the medium may benefit from premedication with corticosteroids and diphenhydramine; the use of nonionic contrast or an alternative noncontrast imaging study, if available, may be considered for patients who have severe asthma or who have experienced moderate to severe reactions to ionic contrast medium.
• high alert Patients with conditions associated with preexisting renal insufficiency (e.g., renal failure, single kidney transplant, nephrectomy, diabetes, multiple myeloma, treatment with aminoglycocides and NSAIDs) because iodinated contrast is nephrotoxic
• high alert Elderly and compromised patients who are chronically dehydrated before the test because of their risk of contrast-induced renal failure.
• high alert Patients with bleeding disorders or receiving anticoagulant therapy because the puncture site may not stop bleeding.
• high alert Patients with severe chronic lung disease, cardiac disease, or advanced liver disease.

Indications

• Determine the extent of adenopathy
• Determine lymphatic cancer staging
• Distinguish primary from secondary lymphedema
• Evaluate edema of an extremity without known cause
• Evaluate effects of chemotherapy or radiation therapy
• Plan surgical treatment or evaluate effectiveness of chemotherapy or radiation therapy in controlling malignant tumors

Potential diagnosis

Normal findings

• Normal lymphatic vessels and nodes that fill completely with contrast medium on the initial films. On 24-hr images, the lymph nodes are fully opacified and well circumscribed. The lymphatic channels are emptied a few hours after injection of the contrast medium

Abnormal findings related to

• Abnormal lymphatic vessels
• Hodgkin’s disease
• Metastatic tumor involving the lymph glands
• Nodal lymphoma
• Retroperitoneal lymphomas associated with Hodgkin’s disease

Critical findings

N/A

Interfering factors

• Factors that may impair clear imaging

  • Gas or feces in the gastrointestinal tract resulting from inadequate cleansing or failure to restrict food intake before the study.
  • Retained barium from a previous radiological procedure.
  • Metallic objects (e.g., jewelry, body rings) within the examination field, which may inhibit organ visualization and cause unclear images.
  • Inability of the patient to cooperate or remain still during the procedure because of age, significant pain, or mental status.
  • Inability to cannulate the lymphatic vessels.

• Other considerations

  • Be aware of risks associated with the contrast medium. The oil-based contrast medium may embolize into the lungs and will temporarily diminish pulmonary function. This can produce lipid pneumonia, which is a life-threatening complication.
  • Consultation with a health-care provider (HCP) should occur before the procedure for radiation safety concerns regarding younger patients or patients who are lactating. Pediatric & Geriatric Imaging Children and geriatric patients are at risk for receiving a higher radiation dose than necessary if settings are not adjusted for their small size. Pediatric Imaging Information on the Image Gently Campaign can be found at the Alliance for Radiation Safety in Pediatric Imaging (www.pedrad.org/associations/5364/ig/).
  • Risks associated with radiation overexposure can result from frequent x-ray procedures. Personnel in the room with the patient should wear a protective lead apron, stand behind a shield, or leave the area while the examination is being done. Personnel working in the examination area should wear badges to record their level of radiation exposure.
  • Failure to follow dietary restrictions and other pretesting preparations may cause the procedure to be canceled or repeated.

Nursing Implications and Procedure

Pretest

• Positively identify the patient using at least two unique identifiers before providing care, treatment, or services.
• Patient Teaching: Inform the patient this procedure can assist in assessing the lymphatic system.
• Obtain a history of the patient’s complaints or clinical symptoms, including a list of known allergens, especially allergies or sensitivities to latex, anesthetics, contrast medium, or sedatives.
• Obtain a history of the patient’s endocrine and immune systems, symptoms, and results of previously performed laboratory tests and diagnostic and surgical procedures.
• Note any recent procedures that can interfere with test results, including examinations using barium- or iodine-based contrast medium. Ensure that barium studies were performed more than 4 days before lymphangiography.
• Record the date of the last menstrual period and determine the possibility of pregnancy in perimenopausal women.
• Obtain a list of the patient’s current medications, including herbs, nutritional supplements, and nutraceuticals (see Effects of Natural Products on Laboratory Values online at DavisPlus).
• Note that if iodinated contrast medium is scheduled to be used in patients receiving metformin (Glucophage) for non-insulin-dependent (type 2) diabetes, the drug should be discontinued on the day of the test and continue to be withheld for 48 hr after the test. Iodinated contrast can temporarily impair kidney function, and failure to withhold metformin may indirectly result in drug-induced lactic acidosis, a dangerous and sometimes fatal side effect of metformin related to renal impairment that does not support sufficient excretion of metformin.
• Review the procedure with the patient. Address concerns about pain and explain there may be moments of discomfort and some pain experienced during the test. Inform the patient that the procedure is performed by an HCP, with support staff, and takes approximately 1 to 2 hr. Inform the patient that he or she will have to return the next day, and the set of images taken upon return will take only 30 min.
• Sensitivity to social and cultural issues, as well as concern for modesty, is important in providing psychological support before, during, and after the procedure.
• Instruct the patient to remove jewelry and other metallic objects from the area to be examined prior to the procedure.
• Instruct patient to withhold anticoagulant medication or to reduce dosage before the procedure, as ordered by the HCP.
• Note that there are no food or fluid restrictions unless by medical direction.
• Make sure a written and informed consent has been signed prior to the procedure and before administering any medications.

Intratest

• Potential complications:

• Injection of contrast medium is an invasive procedure. Complications are rare but do include risk for allergic reaction related to contrast reaction, bleeding from the puncture site related to a bleeding disorder, or the effects of natural products and medications known to act as blood thinners, hematoma related to blood leakage into the tissue following needle insertion, infection that might occur if bacteria from the skin surface is introduced at the puncture site, dyspnea, pain, or hypotension caused by micropulmonary emboli, and lipoid pneumonia caused by contrast flowing into the thoracic duct.

• Observe standard precautions, and follow the general guidelines in Patient Preparation and Specimen Collection. Positively identify the patient.
• Ensure the patient has complied with medication restrictions and pretesting preparations.
• Ensure the patient has removed all external metallic objects from the area to be examined.
• Administer ordered prophylactic steroids or antihistamines before the procedure if the patient has a history of allergic reactions to any substance or drug. Use nonionic contrast medium for the procedure.
• Avoid the use of equipment containing latex if the patient has a history of allergic reaction to latex.
• Have emergency equipment readily accessible.
• Instruct the patient to void prior to the procedure and to change into the gown, robe, and foot coverings provided.
• Instruct the patient to cooperate fully and to follow directions. Direct the patient to remain still throughout the procedure because movement produces unreliable results.
• Obtain and record baseline vital signs, and assess neurological status.
• Administer a mild sedative, as ordered.
• Place the patient in a supine position on an x-ray table. Cleanse the selected area and cover with a sterile drape.
• A local anesthetic is injected at the site, and a small incision is made or a needle inserted. A blue dye is injected intradermally into the area between the toes or fingers. The lymphatic vessels are identified as the dye moves. A local anesthetic is then injected into the dorsum of each foot or hand, and a small incision is made and cannulated for injection of the contrast medium.
• The contrast medium is then injected, and the flow of the contrast medium is followed by fluoroscopy or images. When the contrast medium reaches the upper lumbar level, the infusion of contrast medium is discontinued. X-ray images are taken of the chest, abdomen, and pelvis to determine the extent of filling of the lymphatic vessels. To examine the lymphatic nodes and to monitor the progress of delayed flow, 24-hr delayed images are taken.
• Monitor the patient for complications related to the contrast medium (e.g., allergic reaction, anaphylaxis, bronchospasm, lipid pneumonia).
• Remove the needle or catheter and apply a pressure dressing over the puncture site.
• Observe/assess the needle/catheter insertion site for bleeding, inflammation, or hematoma formation.
• When the cannula is removed the incision is sutured and bandaged.

Post-Test

• Inform the patient that a report of the results will be made available to the requesting HCP, who will discuss the results with the patient.
• Monitor vital signs and neurological status every 15 min for 30 min. Take temperature every 4 hr for 24 hr. Monitor intake and output at least every 8 hr. Compare with baseline values. Notify the HCP if temperature is elevated. Protocols may vary among facilities.
• Observe/assess the cannula insertion site for bleeding, inflammation, or hematoma formation.
• Observe for a delayed allergic reaction to contrast medium or pulmonary embolus, which may include shortness of breath, increased heart rate, pleuritic pain, hypotension, low-grade fever, and cyanosis.
• Instruct the patient to immediately report symptoms such as fast heart rate, difficulty breathing, skin rash, itching, chest pain, persistent right shoulder pain, or abdominal pain. Immediately report symptoms to the appropriate HCP.
• Instruct the patient in the care and assessment of the site.
• Instruct the patient to apply cold compresses to the puncture site as needed to reduce discomfort or edema.
• Instruct the patient to maintain bedrest up to 24 hr to reduce extremity swelling after the procedure, or as ordered.
• Instruct the patient to resume usual medications, as directed by the HCP.
• Recognize anxiety related to test results, and be supportive of perceived loss of independent function. Discuss the implications of abnormal test results on the patient’s lifestyle. Provide teaching and information regarding the clinical implications of the test results, as appropriate.
• Reinforce information given by the patient’s HCP regarding further testing, treatment, or referral to another HCP. Answer any questions or address any concerns voiced by the patient or family.
• Depending on the results of this procedure, additional testing may be needed to evaluate or monitor progression of the disease process and determine the need for a change in therapy. Evaluate test results in relation to the patient’s symptoms and other tests performed.

Related Monographs

• Related tests include biopsy bone marrow, biopsy lymph nodes, CBC, CBC WBC count and differential, CT abdomen, CT pelvis, CT thoracic, gallium scan, laparoscopy abdominal, liver and spleen scan, MRI abdomen, mediastinoscopy, and US lymph nodes.
• Refer to the Endocrine and Immune systems tables at the end of the book for tests by related body system.