{"entity":{"id":"midline-catheters-for-anticancer-therapy","kind":"protocol","name":"Midline catheters in cancer care: when to use one, insertion, care and limits","aka":["midline","midline catheter","MC","extended dwell peripheral catheter","midline for chemotherapy","midline vs PICC"],"tldr":"A midline is a longer drip tube put into a vein in the upper arm, with its tip still in the arm rather than near the heart. It avoids repeated needles, and it carries fewer bloodstream infections than a PICC. Whether it is safe for chemotherapy that can damage tissue if it leaks has not been settled.","summary":"A midline is a peripheral device: its tip lies in the upper arm or axillary vein, not in a central vein. CDC/HICPAC (2011) advises a midline or PICC instead of a short cannula when intravenous therapy will likely exceed six days (Category II), daily site checks, replacement only for a specific indication (II), and prompt removal when it is no longer essential (IA). The Italian SIMiC bundle (2026) sets seven insertion steps: ultrasound assessment of the arm and chest veins, choice of an upper-arm vein, hand hygiene, antisepsis and maximal barrier precautions, ultrasound-guided puncture, intra-procedural ultrasound tip location, sutureless securement and glue with a transparent dressing.\n\nAgainst PICCs, a 2026 meta-analysis of 15 studies (over 27,000 patients) found PICCs had about four times the risk of catheter-related bloodstream infection (RR 4.18), with no difference in thrombosis, failure, occlusion or phlebitis; a second 2026 meta-analysis (29,680 catheters) found similar venous thromboembolism rates (3.5% against 3.8%). In cancer, a Japanese prospective study of 59 patients having continuous fluorouracil for at least four days found no phlebitis with a midline; and a systematic review found midlines and PICCs safe for symptom control in palliative care. The open question is vesicants: no guideline read says whether continuous or repeated vesicant chemotherapy may run through a midline, and the Japanese extravasation guideline cites a case report of oxaliplatin extravasation from one.","asOf":"2026-11-11","links":[],"tags":[],"related":["peripheral-cannula-for-anticancer-therapy","venous-access-device-selection-for-anticancer-therapy","central-venous-catheter-insertion-for-anticancer-therapy"],"cancers":[],"sections":[],"technologies":["infusion-devices-vascular-access","catheter-securement-devices"],"targets":[],"drugs":["fluorouracil"],"companies":[],"institutions":[],"pathways":[],"terms":[],"trials":[],"people":[],"bottlenecks":[],"keyPapers":[],"journals":[],"dependsOn":[],"notes":[],"simple":"A midline is a longer tube in an upper-arm vein for drips over days or weeks. Ask your team whether your treatment can go through one.","domain":"vascular-access","setting":{"who":["nurse","doctor"],"where":["ward","chemotherapy-day-unit","outpatient-clinic","community"]},"population":"Adults with cancer needing intravenous access for more than about six days without a central device, for supportive treatment, antibiotics, symptom control or selected anticancer infusions. Children and long courses of chemotherapy, where a port or PICC is usually chosen (see the device-selection protocol), are not covered.","trigger":"Intravenous therapy is expected to last more than about six days and a central device is not needed or not wanted.","steps":[{"action":"Choose a midline or PICC rather than a short cannula when intravenous treatment will likely last more than six days","why":"A short cannula usually fails within days; a longer device avoids repeated needles.","source":"cdc-hicpac-2011","quote":"Use a midline catheter or peripherally inserted central catheter (PICC), instead of a short peripheral catheter, when the duration of IV therapy will likely exceed six days.","grade":"Category II"},{"action":"Insert it as a bundle: ultrasound assessment of the veins, an upper-arm vein, hand hygiene, skin antisepsis and maximal barriers, ultrasound-guided puncture, ultrasound tip location, sutureless securement and a sealed transparent dressing","why":"Each step lowers the chance of a failed attempt, an infection, a clot or the line falling out.","source":"simic-2026","quote":"The SIMiC bundle includes seven steps: (1) systematic ultrasound evaluation of the veins of the arms and the supra/infra-clavicular area; (2) choice of the most appropriate vein of the upper arm; (3) appropriate hand hygiene, proper skin antisepsis, and maximal barrier precautions; (4) ultrasound-guided venipuncture; (5) intra-procedural tip location, using infra/supraclavicular ultrasound scan; (6) sutureless securement, preferably using subcutaneous anchorage; (7) protection of the exit site with cyanoacrylate glue and semipermeable transparent membrane."},{"action":"Check the site every day, through the dressing, for tenderness, redness or swelling","why":"Early signs of infection, phlebitis or a leak are found by looking and feeling.","source":"cdc-hicpac-2011","quote":"Evaluate the catheter insertion site daily by palpation through the dressing to discern tenderness and by inspection if a transparent dressing is in use.","grade":"Category II"},{"action":"Do not replace a working midline on a schedule; replace it only for a specific reason","why":"Routine replacement adds procedures without benefit.","source":"cdc-hicpac-2011","quote":"Replace midline catheters only when there is a specific indication.","grade":"Category II"},{"action":"Take the midline out as soon as it is no longer needed","why":"Every day a line stays in adds to the risk of infection and clots.","source":"cdc-hicpac-2011","quote":"Promptly remove any intravascular catheter that is no longer essential [69–72].","grade":"Category IA"}],"bestInClass":{"statement":"Use a midline (or PICC) when intravenous therapy will likely exceed six days (CDC Category II), insert it with an ultrasound-guided bundle (SIMiC 2026), check it daily, replace it only for a reason (CDC II) and remove it promptly (CDC IA). Compared with PICCs, midlines carry fewer bloodstream infections and similar thrombosis risk (2026 meta-analyses). For anticancer drugs, the only cancer-specific evidence read is for continuous fluorouracil (Sakakida 2025); whether vesicants may be given through a midline is unresolved in the sources read, and the INS Standards that address it could not be read.","sources":["cdc-hicpac-2011","simic-2026","aljameie-2026","santagata-2026","sakakida-2025"]},"variants":[{"name":"Midline for continuous fluorouracil","differs":"Gives continuous fluorouracil over four days or more through an upper-arm midline with its tip in the axillary vein, instead of a short cannula or a central line.","evidence":"In a prospective Japanese study of 59 patients (mostly oesophageal and head and neck cancer), no phlebitis occurred (0%, 95% CI 0 to 6.2%), insertion succeeded in 98.3% and complications occurred in 6.8%; median dwell 5.5 days.","sources":["sakakida-2025"]},{"name":"Midline for symptom control in palliative care","differs":"Uses a midline or PICC for weeks of intravenous symptom treatment or parenteral nutrition in people with advanced cancer.","evidence":"A systematic review of 17 studies (moderate or weak quality) found complications of 0 to 2.46 per 1,000 catheter days and high patient satisfaction.","sources":["gravdahl-2024"]}],"grades":[],"sources":[{"key":"cdc-hicpac-2011","label":"Guidelines for the Prevention of Intravascular Catheter-Related Infections, 2011 (last update October 2017)","publisher":"CDC/HICPAC","year":2011,"url":"https://www.cdc.gov/infection-control/media/pdfs/Guideline-BSI-H.pdf","gradingScheme":"Category IA (strongly recommended, strongly supported by well-designed studies), IB (strongly recommended, some studies and strong rationale, or accepted practice), IC (required by regulation), II (suggested), Unresolved issue.","read":"full-text","accessed":"2026-11-11"},{"key":"simic-2026","label":"A GAVeCeLT-IVAS bundle for the Safe Insertion of Midline Catheters: The SIMiC protocol","publisher":"Journal of Vascular Access (GAVeCeLT and IVAS)","year":2026,"url":"https://doi.org/10.1177/11297298261445794","doi":"10.1177/11297298261445794","read":"abstract","accessed":"2026-11-11"},{"key":"magic-onc-2025","label":"The Michigan Appropriateness Guide for Intravenous Catheters in Adult Patients With Cancer (MAGIC-ONC)","publisher":"Annals of Internal Medicine","year":2025,"url":"https://doi.org/10.7326/ANNALS-25-02523","doi":"10.7326/ANNALS-25-02523","gradingScheme":"RAND/UCLA Appropriateness Method: scenarios rated appropriate, neutral/uncertain or inappropriate.","read":"abstract","accessed":"2026-11-11"},{"key":"sakakida-2025","label":"Midline catheter use for cancer patients receiving 5-FU chemotherapy: prospective study of safety and outcomes","publisher":"The Oncologist (Sakakida et al.)","year":2025,"url":"https://doi.org/10.1093/oncolo/oyaf108","doi":"10.1093/oncolo/oyaf108","read":"abstract","accessed":"2026-11-11"},{"key":"aljameie-2026","label":"Comparative safety and effectiveness of midline catheters vs. peripherally inserted central catheters: a systematic review and meta-analysis","publisher":"Frontiers in Cardiovascular Medicine (Aljameie et al.)","year":2026,"url":"https://doi.org/10.3389/fcvm.2026.1890087","doi":"10.3389/fcvm.2026.1890087","read":"abstract","accessed":"2026-11-11"},{"key":"santagata-2026","label":"Venous Thromboembolism Risk Associated with MIDLINE Catheters and Peripherally Inserted Central Catheters, a Systematic Review and Meta-Analysis","publisher":"Thrombosis and Haemostasis (Santagata et al.)","year":2026,"url":"https://doi.org/10.1055/a-2810-4737","doi":"10.1055/a-2810-4737","read":"abstract","accessed":"2026-11-11"},{"key":"gravdahl-2024","label":"Use of peripherally inserted central venous catheters and midline catheters for palliative care in patients with cancer: a systematic review","publisher":"Supportive Care in Cancer (Gravdahl et al.)","year":2024,"url":"https://doi.org/10.1007/s00520-024-08664-3","doi":"10.1007/s00520-024-08664-3","read":"abstract","accessed":"2026-11-11"},{"key":"ins-2024","label":"Infusion Therapy Standards of Practice, 9th Edition","publisher":"Infusion Nurses Society (Journal of Infusion Nursing)","year":2024,"url":"https://doi.org/10.1097/NAN.0000000000000532","doi":"10.1097/NAN.0000000000000532","read":"not-reachable","accessed":"2026-11-11"}],"upgrades":["idea-upgrade-midline-vesicant-safety-study"],"gaps":["Whether vesicant or irritant chemotherapy may be given through a midline is not answered by any source read; the INS Standards (2024), which address infusate limits for midlines, and MAGIC-ONC's full ratings could not be read. The Japanese extravasation guideline (2024) cites a case report of oxaliplatin extravasation from a midline.","OnCo has no technology record for midline catheters; this protocol links the general vascular access record.","All the midline evidence here was read as abstracts; the meta-analyses mix inpatients and intensive care with few people having cancer treatment."]},"route":"/protocols/midline-catheters-for-anticancer-therapy/","neighbours":{"protocol":[{"id":"central-venous-catheter-insertion-for-anticancer-therapy","kind":"protocol","name":"Central venous catheter insertion for anticancer treatment: PICC, tunnelled line and implanted port","route":"/protocols/central-venous-catheter-insertion-for-anticancer-therapy/"},{"id":"venous-access-device-selection-for-anticancer-therapy","kind":"protocol","name":"Choosing a venous access device for anticancer treatment: port, PICC, tunnelled line or cannula","route":"/protocols/venous-access-device-selection-for-anticancer-therapy/"},{"id":"peripheral-cannula-for-anticancer-therapy","kind":"protocol","name":"Peripheral cannula for anticancer treatment: vein choice, siting and checks, including vesicants","route":"/protocols/peripheral-cannula-for-anticancer-therapy/"}],"technology":[{"id":"catheter-securement-devices","kind":"technology","name":"Catheter securement devices and dressings (SecurAcath, Tegaderm CHG)","route":"/technologies/catheter-securement-devices/"},{"id":"infusion-devices-vascular-access","kind":"technology","name":"Infusion pumps, ports, and ambulatory chemotherapy devices","route":"/technologies/infusion-devices-vascular-access/"}],"drug":[{"id":"fluorouracil","kind":"drug","name":"Fluorouracil (5-FU)","route":"/drugs/fluorouracil/"}],"idea":[{"id":"idea-upgrade-midline-vesicant-safety-study","kind":"idea","name":"Find out whether vesicant and irritant chemotherapy can safely run through a midline catheter","route":"/ideas/idea-upgrade-midline-vesicant-safety-study/"}]}}