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If your chemotherapy goes in through a small tube (cannula) in a vein in your arm, the nurse should choose a good vein in the forearm, avoid joints and the back of the hand, put in a fresh cannula, check it works before and during the drip, and ask you to say at once if it stings, burns or swells.
Most guidance on peripheral cannulas comes from infection prevention, and much of the chemotherapy-specific detail from extravasation guidelines. The most recent graded guideline on the subject, the Japanese JSCN/JSMO/JASPO extravasation guideline (2024, GRADE), weakly recommends a central venous device rather than peripheral veins for people starting anticancer drugs (certainty B), recommends siting a peripheral cannula upstream (closer to the heart) of any previous puncture (weak, C), recommends against routine timed replacement of a peripheral cannula during anticancer treatment (weak, C), and, unless strict rate control is needed, weakly recommends against an infusion pump for peripheral anticancer infusions (C).
CDC/HICPAC (2011, updated 2017) asks for an upper-limb site in adults (Category II), never a steel needle for anything that can cause necrosis if it leaks (IA), and a midline or PICC rather than a short cannula when therapy will likely exceed six days (II); it finds no need to replace peripheral catheters more often than every 72 to 96 hours (IB) and makes no recommendation on replacing only when clinically indicated. epic3 asks for 2% chlorhexidine in 70% alcohol, allowed to dry, before insertion (Class D/GPP). Practice detail comes from UK network guidance (West Midlands, 2017): avoid joints, the antecubital fossa and the back of the hand; prefer large forearm veins; use a new cannula, the smallest gauge in the largest vein; repeat attempts above the previous site; check for blood return before and throughout; give vesicants first; consider central access for long vesicant infusions or after a previous extravasation.
Why: Central devices avoid repeated needle sticks and make it less likely a drug leaks into the arm.
“It is weakly recommended to place a CV device in patients planning to receive anticancer drugs.”
ESMO Open (Japanese Society of Cancer Nursing, Japanese Society of Medical Oncology, Japanese Society of Pharmaceutical Oncology) 2024 · Recommend (weak), certainty B
Why: Arm veins carry less risk of infection and clots than leg veins.
“In adults, use an upper-extremity site for catheter insertion.”
CDC/HICPAC 2011 · Category II
Why: If a drug leaks where there is little soft tissue, tendons and nerves can be damaged; a big vein dilutes the drug quickly.
“Cannulating over joints, the anticubital fossa or dorsum of the hand should be avoided as tissue damage due to extravasation may have serious consequences as there is little soft tissue for the protection of underlying nerves and tissues.”
West Midlands Expert Advisory Group for SACT (NHS England) 2017
Why: It kills skin bacteria that could otherwise enter the vein with the cannula.
“Decontaminate the skin at the insertion site with a single-use application of 2% chlorhexidine gluconate in 70% isopropyl alcohol (or povidone iodine in alcohol for patients with sensitivity to chlorhexidine) and allow to dry before inserting a peripheral vascular access device.”
Journal of Hospital Infection (Loveday et al., commissioned by the Department of Health) 2014 · Class D/GPP
Why: Steel needles slip out of the vein more easily, and a drug that leaks can destroy tissue.
“Avoid the use of steel needles for the administration of fluids and medication that might cause tissue necrosis if extravasation occurs [33, 34]. Category IA”
CDC/HICPAC 2011 · Category IA
Why: A drug given below a fresh puncture can leak out through the hole higher up the vein.
“It is weakly recommended to place a peripheral venous catheter centrally (upstream) from the site of preceding puncture for patients receiving anticancer drug therapy from the peripheral veins.”
ESMO Open (Japanese Society of Cancer Nursing, Japanese Society of Medical Oncology, Japanese Society of Pharmaceutical Oncology) 2024 · Recommend (weak), certainty C
Why: A cannula that has slipped out of the vein lets the drug leak into the tissue.
“Venous access should be assessed and tested immediately prior to and frequently throughout administration of any cytotoxic drugs, checking for backflow, no resistance on syringe plunger on administration and acceptance of free flowing compatible infusion fluid”
West Midlands Expert Advisory Group for SACT (NHS England) 2017
Why: Routine re-siting causes pain and uses up veins without reducing leaks.
“It is weakly recommended not to replace peripheral venous catheters with specific time interval in patients receiving anticancer drugs.”
ESMO Open (Japanese Society of Cancer Nursing, Japanese Society of Medical Oncology, Japanese Society of Pharmaceutical Oncology) 2024 · Not recommend (weak), certainty C
Why: A pump keeps pushing fluid even if the cannula has slipped, so a leak can grow before anyone notices.
“Unless strict dose rate control is required, avoidance of infusion pump is weakly recommended when administering anticancer drugs via the peripheral vein.”
ESMO Open (Japanese Society of Cancer Nursing, Japanese Society of Medical Oncology, Japanese Society of Pharmaceutical Oncology) 2024 · Recommend or not recommend (weak), certainty C
Why: The person often feels a leak before anyone can see it.
“Patients should be informed of the importance of reporting immediately any change in sensation, stinging or burning during the administration of chemotherapy”
West Midlands Expert Advisory Group for SACT (NHS England) 2017
How care is usually carried out, read from the guidelines and standards cited. Your own team's protocol and their judgement come first; this page is for understanding it, not for doing it yourself.
Consider a central device first (JSCN 2024, weak, B; MAGIC-ONC 2025 for device choice). If a peripheral vein is used: an upper-limb site (CDC II), chlorhexidine-alcohol skin preparation allowed to dry (epic3 D/GPP), never a steel needle (CDC IA), repeat attempts upstream of earlier punctures (JSCN weak, C), no routine timed replacement (JSCN weak, C), gravity rather than a pump unless strict rate control is needed (JSCN weak, C), and patency checks before and throughout. Guidelines differ on replacement: CDC sees no need to replace more often than every 72 to 96 hours and makes no recommendation on replacing only when clinically indicated, while JSCN recommends against timed replacement during anticancer treatment. Vein choice within the arm (forearm, avoiding joints, the antecubital fossa and the back of the hand) rests on UK network guidance and expert sources, not trials.
ESMO Open (Japanese Society of Cancer Nursing, Japanese Society of Medical Oncology, Japanese Society of Pharmaceutical Oncology) 2024 · CDC/HICPAC 2011 · Journal of Hospital Infection (Loveday et al., commissioned by the Department of Health) 2014 · West Midlands Expert Advisory Group for SACT (NHS England) 2017 · Annals of Internal Medicine 2025
Where it differs: Adds a new cannula sited immediately before treatment, the smallest gauge in the largest vein, no more than two attempts by one practitioner, vesicants given first while the vein is at its best, a clear dressing with the site always visible, and central access for vesicant infusions of 12 to 24 hours or after a previous extravasation.
Evidence: Network guidance citing nursing texts and expert sources, not trials; past its own review date (July 2019).
West Midlands Expert Advisory Group for SACT (NHS England) 2017
Where it differs: Six steps for every short cannula: examine both arms with and without a tourniquet, avoid areas of flexion and prefer forearm veins or the upper-arm cephalic vein, hand hygiene and skin antisepsis, cannula-over-needle insertion with a tourniquet, connection, and securement with protection of the exit site.
Evidence: An Italian society consensus bundle described as evidence-based, not specific to anticancer drugs; read as an abstract.
Where it differs: Re-sites peripheral cannulas at a fixed interval to reduce infection and phlebitis.
Evidence: CDC (IB) says there is no need to replace more often than every 72 to 96 hours in adults, and leaves replacement only when clinically indicated as an unresolved issue. JSCN 2024 found routine replacement reduced infiltration but not extravasation and judged that its harms outweigh its benefit during anticancer treatment.
CDC/HICPAC 2011 · ESMO Open (Japanese Society of Cancer Nursing, Japanese Society of Medical Oncology, Japanese Society of Pharmaceutical Oncology) 2024
| Recommendation | Grade, as printed | Source |
|---|---|---|
| Use a midline or PICC instead of a short peripheral cannula when IV therapy will likely exceed six days “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.” | Category II | CDC/HICPAC 2011 |
| No need to replace peripheral catheters more often than every 72 to 96 hours in adults “There is no need to replace peripheral catheters more frequently than every 72-96 hours to reduce risk of infection and phlebitis in adults [36, 140, 141].” | Category IB | CDC/HICPAC 2011 |
| Replacing peripheral catheters in adults only when clinically indicated “No recommendation is made regarding replacement of peripheral catheters in adults only when clinically indicated [142–144].” | Unresolved issue | CDC/HICPAC 2011 |
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