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When administering chemotherapy drugs intravenously to a patient, certain factors need to be considered in order to maximize safety and comfort.
First and foremost, the nature of the chemotherapy drug(s) being administered must be determined. Whether the drug(s) is a vesicant, irritant, or neither will have considerable bearing on the following issues:
Selection of Peripheral IV Site
The preferred site for establishing an intravenous for the purposes of chemotherapy administration is:
- A large superficial vein on the forearm between the wrist and antecubital fossa.
- Away from areas of bruising.
- Proximal to venipuncture sites established within the preceding 24 hours.
- Away from joints or tendons.
Hand veins may be used, and may be easier to observe in some patients, however, extravasation of a vesicant drug in this area can cause severe damage. Based on individual patient assessment, the placement of an intravenous device may be contraindicated in one or both arms. Assessment parameters include:
- Presence of edema
- History of superior vena cava obstruction
- Lymphatic obstruction
- Previous phlebitis
- Prior radiation therapy to the upper torso
- Lymph node dissection
- Radical/modified radical mastectomy
- alteration of sensation of extremities
None of these parameters automatically preclude IV access, but the presence of any one needs to be taken into consideration and the physician consulted as appropriate. Veins in lower extremities are used as a last resort when both arms are contraindicated.
If at all possible, the person who initiates the IV should be the person who administers the chemotherapy. It is preferable to establish a new IV site for chemotherapy administration rather than using a pre-existing IV.
The considerations discussed above are particularly important when the drug to be administered is a vesicant, because of the tissue destruction that can occur if a vesicant extravasates out of the vein into the tissues (See Appendix 2).
Type and Size of Peripheral IV Device
The general rule for selection of an IV device is to use the smallest gauge catheter/needle that will deliver the drug at the required rate. A smaller gauge needle/catheter has the following advantages:
- less likely to puncture the wall of a smaller vein
- less scar tissue formed with frequent venipunctures
- increased blood flow around the needle allows for greater and faster dilution of chemotherapy drugs
- may decrease mechanical phlebitis
A needle/catheter guage between #21 and #25 is the preferred choice for chemotherapy administration.
Either a metal needle (e.g. "butterfly") or "over the needle" catheter (e.g. Jelco, Intima) style of device may be used depending on the type of chemotherapy and assessment of the patient's venous status.
In choosing a device consider the following:
| Metal Needle |
Flexible Catheter |
- less damage on insertion therefore less painful insertion
- good visibility at needle tip
- rigid needle has increased risk of infiltration with longer infusion time
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- decreased incidence of infiltration
- decreased visibility at needle tip
- blood return may be more difficult to assess
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Use of Central Venous Access Device
Chemotherapy may be administered via a central venous access device and standard practices around the use and care of central venous access devices apply. It is essential to confirm that the device is patent and functioning prior to administering chemotherapy, particularly if the drug is a vesicant. This can be established by aspirating for blood return upon accessing the device. Infusing a bolus of 25-100 ml of normal saline to ensure free flow without local discomfort or swelling will also serve to check the functioning of the device.
In some instances, the insertion of a central venous access device may be required in order to ensure safety and comfort for the patient. The following are examples of such situations:
- when a vesicant drug is to be administered as an infusion
- when a patient with extremely poor peripheral venous access will be receiving a vesicant or irritant drug
Sequence of Drug Administration
Sequence of drug administration may be determined by the particular treatment plan. If this is not the case the following issues should be considered:
| Vesicant/Irritant First |
Vesicant/Irritant Last |
- venous integrity is good
- vein is most stable and less irritated
- assessment of vein patency is most accurate
- less chance of compromised vascular integrity
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- vesicants are irritating and may increase vein fragility
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The recommended practice is to administer vesicants first.
Methods of Administration
The method of IV administration will be determined by the treatment plan and the type of chemotherapy drugs.
| Method |
Definition |
Indications for Use |
| Infusion |
Intermittent or continuous infusion of cytotoxic agents via secondary medication line. |
- Non-vesicant cytotoxics via peripheral IV
- Vesicant or non-vesicant cytotoxics via functioning central venous catheter.
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| Side Arm |
Administration of cytotoxics through lowest medication port of freeflowing IV.
Check blood return and assess site for infiltration every 2-3 ml of drug injected. |
- Vesicants via peripheral line, to ensure venous integrity throughout procedure.
- Push administration of non-vesicants into established IV, where the agents can be given without further dilution.
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| Direct IV |
Cytotoxic given direct IV via steel needle or "over the needle" catheter |
- Non-vesicant cytotoxics not requiring dilution or accompanying hydration.
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Source: British Columbia Cancer Agency, Cancer Drug Manual 1994. Used with permission.
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