Evidence summary of nursing care of arterial drug administration and catheter management for HAIC in hepatocellular carcinoma

Abstract

Background:

This study aimed to summarize and grade the existing evidence on continuous hepatic artery infusion chemotherapy (HAIC) arterial drug administration and catheter care, providing evidence-based guidance for clinical nursing decisions.

Methods:

Using the “6S” pyramid model, We searched 10 electronic resources (UpToDate, Joanna Briggs Institute [JBI], Cochrane Library, Web of Science, Embase, PubMed, EBSCOhost Research Platform, China National Knowledge Infrastructure, Wanfang, and SinoMed) and 5 professional organization websites (National Comprehensive Cancer Network, the American Society of Clinical Oncology, the Japan Society of Clinical Oncology, the Oncology Nursing Society, and the Multinational Association of Supportive Care in Cancer/European Society for Medical Oncology) from inception to March 31, 2024. Quality appraisal tools were selected by evidence type: Appraisal of Guidelines for Research and Evaluation II for guidelines, JBI critical appraisal tools for systematic reviews/meta-analyses and JBI standards for expert consensus, and the Critical Appraisal for Summaries of Evidence tool for evidence summaries. Evidence was graded using the JBI levels of evidence (2014).

Results:

We identified 769 records and included 12 publications (1 guideline, 2 systematic reviews, 4 meta-analyses, 2 evidence summaries, and 3 expert consensus documents). A total of 36 evidence statements were organized into 4 domains: HAIC puncture care (8), medication care (15), complication prevention and management (10), and catheter removal care (3). Evidence levels ranged from 1b to 5b.

Conclusion:

This evidence summary offers clear, graded recommendations to guide continuous arterial drug administration and catheter care in HAIC. The evidence can be used to develop or update local protocols and to support bedside decisions on HAIC drug delivery and catheter management. Implementation should be tailored to local healthcare settings by considering workflow, device availability, staffing capacity, and patient risk profiles to optimize safety and feasibility.

What we investigated and why

Hepatic artery infusion chemotherapy has become a critical treatment option for patients with unresectable advanced liver cancer, helping to extend survival and create opportunities for surgery. This study focuses on drug administration and catheter care, using an evidence-based approach to develop best practices. These practices offer clinical nursing teams and patients scientific, practical, and cost-effective management strategies to ensure safe medication use and reduce adverse events.

How we conducted the study

This study followed the Evidence Summary Reporting Standards of Fudan University’s Evidence-Based Nursing Center. The report was developed based on the Joanna Briggs Institute’s evidence summary methodology, involving processes such as problem formulation, literature search, screening, quality assessment, evidence extraction, and classification to generate the final evidence entries.

1. Introduction

Primary liver cancer is a malignancy with a high incidence rate worldwide, ranking 3rd among the leading causes of cancer-related deaths globally.^[1] According to Global Cancer Observatory 2022, liver cancer accounted for approximately 866,000 new cases and 759,000 deaths worldwide, with the majority of cases occurring in Asia.^[2] China contributes a substantial proportion of the global burden.^[3] Although surgical resection remains the only curative treatment for liver cancer, most patients with advanced-stage liver cancer lose the opportunity for surgery by the time they are diagnosed.^[4] Consequently, interventional therapies have become a crucial treatment option for patients with unresectable advanced liver cancer.

Hepatic arterial infusion chemotherapy (HAIC) involves delivering chemotherapeutic agents directly into the liver’s target lesion area via a hepatic arterial port or an indwelling arterial catheter. Regarding clinical practice guidelines, the Barcelona Clinic of Liver Cancer group and the National Comprehensive Cancer Network recommend systemic therapies as the primary approach for extensive disease.^[5,6] While Asian groups, including those in Korea, Japan, and China, suggest systemic therapies and HAIC as potential treatment options for these patients.^[7,8]

Both transarterial chemoembolization (TACE) and HAIC have demonstrated efficacy in advanced or unresectable HCC.^[9] Unlike TACE, HAIC emphasizes continuous arterial drug administration. This sustained delivery is critical for time-dependent drugs like 5-fluorouracil, which require prolonged exposure for optimal cytotoxicity. It can also increase intrahepatic exposure to concentration-dependent agents such as oxaliplatin through local arterial delivery.^[10] The infusion typically lasts 24 to 48 hours and uses portable infusion pumps.^[11] Comparative studies suggest that HAIC may offer a superior objective response rate, disease control rate, and overall survival compared to TACE in patients with unresectable HCC.^[12,13]

However, the unique administration mode of HAIC presents significant challenges. The requirement for prolonged continuous infusion via an indwelling arterial catheter imposes distinct technical and safety demands on nursing staff. These demands include the management of catheter displacement, arterial thrombosis, and pump malfunction.^[14] Despite the established clinical consensus on medical regimens, a critical knowledge gap remains regarding nursing practice. Current guidelines primarily focus on therapeutic efficacy and patient selection, while nursing-specific recommendations for arterial catheter care and infusion safety are often fragmented or insufficiently operationalized for bedside decision-making. Consequently, there is a lack of a unified, evidence-based protocol to guide nurses in managing these complex procedures.

This study aims to evaluate and integrate the evidence on continuous chemotherapy infusion care for patients with indwelling hepatic arterial catheters, using an evidence-based approach to summarize the best available evidence, thereby providing clinical nurses with evidence-based recommendations for scientific and standardized drug administration and arterial catheter care.

2. Methods

2.1. Problem formulation

The evidence-based question was developed using the Fudan University Evidence-Based Nursing Center’s tool for formulating evidence-based questions.

• Population (P): Adult liver cancer patients receiving continuous chemotherapy infusion through indwelling hepatic arterial catheters.

• Intervention (I): A bundled care approach defined as a protocolized package of evidence-informed nursing actions delivered together.^[15] It includes arterial catheter fixation techniques, continuous drug administration care, complication prevention, patient education, and self-management guidance.

• Setting (S): Departments of hepatobiliary and pancreatic surgery, oncology, and interventional radiology.

• Type of evidence (T): Clinical decisions, evidence summaries, guidelines, systematic reviews, meta-analyses, and expert consensus documents.

2.2. Evidence search

We retrieved evidence using the 6S hierarchy of evidence, which recommends starting at the highest available level (systems/summaries) and moving downward only when higher-level evidence is insufficient for the clinical question.^[16] Accordingly, we 1st searched UpToDate, Joanna Briggs Institute (JBI), and The Cochrane Library. Comprehensive databases searched included Web of Science, Embase, PubMed, EBSCOhost Research Platform, China Biomedical Literature Database (Sinomed), China National Knowledge Infrastructure, and Wanfang. The search timeframe extended up to March 31, 2024. The search terms included:

• “hepatic arterial infusion chemotherapy” OR “HAIC” OR “hepatic arterial infusion pump” AND “liver cancer” OR “liver neoplasms” OR “carcinoma, hepatocellular” OR “metastatic liver cancer” AND (“guideline” OR “recommendation” OR “standard” OR “consensus” OR “best practice” OR “systematic review” OR “meta-analysis”).

Additionally, we searched professional websites, including the National Comprehensive Cancer Network, the American Society of Clinical Oncology, the Japan Society of Clinical Oncology, the Oncology Nursing Society, and the Multinational Association of Supportive Care in Cancer/European Society for Medical Oncology. Full search strategies for all databases are provided in File S1, Supplemental Digital Content 1.

2.3. Inclusion and exclusion criteria for literature

Inclusion criteria: publications from earlier years were eligible for inclusion if their nursing operational recommendations remained applicable and were not replaced by newer evidence within the search window.

1. Participants aged ≥18 years diagnosed with liver cancer and receiving HAIC.

2. The focus of the study was the nursing care of HAIC.

3. The literature type was clinical decision-making guidelines, evidence summaries, systematic reviews, meta-analyses, and expert consensus papers when higher-level evidence was unavailable or insufficient to address nursing-specific operational questions.

4. Published in Chinese or English because these were the languages accessible to the review team for accurate screening and critical appraisal.

Exclusion criteria:

1. Studies where the full text was unavailable.

2. Incomplete information.

3. Unclear evidence sources.

4. Duplicated articles from multiple databases.

2.4. Quality assessment of literature

Different quality assessment tools were used based on the type of literature. Conflicts of interest and funding disclosures of included publications were not formally extracted or appraised. For all evaluations of guidelines, the ICC values were >0.750, indicating the high consistency and good reliability between the evaluators.

1. Guidelines were evaluated using the Appraisal of Guidelines for Research and Evaluation II instrument,^[17] which covers 6 domains and 23 items. Each item was rated from 1 (strongly disagree) to 7 (strongly agree), and scores for each domain were standardized into percentages. Guidelines with scores >60% in all domains were rated as grade A, while those with ≥3 domains scoring between 30% and 60% were rated grade B, and those with ≥3 domains scoring <30% were rated grade C.

2. Systematic reviews and meta-analyses were assessed using the JBI’s critical appraisal tools for systematic reviews (2016 version).^[18] Items were judged as “yes,” “no,” “unclear,” or “not applicable.” Reviews were classified as high quality when most items were rated “yes” and no critical methodological limitations were identified.

3. Evidence summaries were evaluated using the Critical Appraisal for Summaries of Evidence tool,^[19] which includes 10 items rated as “yes,” “partially,” or “no”: evidence summaries were classified as high quality when most items were rated “yes,” particularly those related to transparent evidence sources, appropriate critical appraisal, and clear linkage between evidence and recommendations.

4. Expert consensus papers were evaluated using the relevant JBI standards.^[20] Items were judged as “yes,” “no,” “unclear,” or “not applicable.” Consensus documents were classified as high quality when the consensus development process and underpinning evidence were clearly reported and most appraisal items were rated “yes.”

Four reviewers trained in evidence-based nursing independently appraised the included guidelines using the Appraisal of Guidelines for Research and Evaluation II instrument, and the scores were cross-checked. Any discrepancies were resolved through group discussion and reexamination of the guideline text; if disagreement persisted, the group leader made the final decision. For other types of literature, 2 reviewers independently conducted appraisal using the corresponding tools, with cross-checking. Disagreements were resolved by reexamining the original sources and discussion; if consensus could not be reached, the group leader acted as a 3rd reviewer to adjudicate and make the final decision.

2.5. Evidence synthesis and grading

Two researchers (SZX and HLQ) independently extracted evidence using a structured extraction form that included evidence topic, description, source, reference, and level. To derive the final set of evidence, raw extractions were synthesized following 3 specific principles: for overlapping evidence, concise and clear recommendations were prioritized; complementary evidence addressing the same theme was logically integrated; and conflicting evidence was resolved by prioritizing newer publications and higher-quality evidence. Disputes were resolved by reexamining source documents, with final adjudication by the group leader as 3rd therapy specialist. Through this process, the initial extractions were consolidated into 36 final pieces of evidence. We used the JBI Levels of Evidence system (2014 version)^[21] to classify evidence into 5 levels based on study design, with level 1 (experimental designs) being the highest and level 5 (expert opinion) the lowest. For clinical guidelines, original sources were traced to ensure accurate grading. In this study, no major conflicting evidence requiring parallel comparison was identified among the included studies.

2.6. Systematic review registration

This evidence summary study utilized the standard of evidence summary report from Fudan University Center for evidence-based Nursing, which includes problem establishment, evidence retrieval, literature screening, quality evaluation of the literature, and the summary and grading of evidence.^[22,23] The registration no. is ES20244006.

3. Results

3.1. Literature screening outcomes

A total of 769 articles were initially identified through the search. After applying the inclusion and exclusion criteria, 12 articles were ultimately included in the review. These included 1 guideline,^[24] 2 systematic reviews,^[25,26] 4 meta-analyses,^[27–30] 2 evidence summaries,^[31,32] and 3 expert consensus papers.^[33–35]

Although HAIC is widely studied, most publications focus on treatment efficacy or patient selection. These 12 studies were selected specifically for their provision of extractable, operational nursing guidance. While the included studies covered diverse patient populations and treatment regimens, the nursing care requirements for arterial access and infusion safety remained consistent across these variations. Studies focused on clinical outcomes were retained when they contained extractable data on symptom management or adverse event monitoring that could directly inform nursing protocols for patient safety. The literature screening flowchart is shown in Figure 1. The general characteristics of the included studies are summarized in Table 1.

Figure 1.

Literature screening flowchart. BMJ = British Medical Journal, CINAHL = Cumulative Index to Nursing and Allied Health Literature, CNKI = China National Knowledge Infrastructure, EBSCO = EBSCOhost Research Platform, JBI = Joanna Briggs Institute.

Table 1.

Characteristics of included studies.

Author/institution	Year of publication	Source	Themes	Type of literature
Taiwan Liver Cancer Association[24]	2017	PubMed	Guidelines for the management of liver cancer	Guideline
Liu et al[25]	2020	PubMed	Effectiveness of HAIC with sorafenib in treating hepatocellular carcinoma patients with portal vein tumor thrombosis	Systematic review/meta-analysis
Yuanren et al[26]	2023	PubMed	Effectiveness of transarterial chemoembolization/HAIC with lenvatinib and PD-1 inhibitors in hepatocellular carcinoma with portal vein tumor thrombosis	Systematic review/meta-analysis
Moran et al[27]	2019	PubMed	Outcomes of liver cancer patients undergoing resection and adjunctive hepatic artery infusion therapy	Systematic review/meta-analysis
Yan et al[28]	2022	PubMed	Efficacy and safety of HAIC and sorafenib in treating advanced liver cancer	Systematic review/meta-analysis
Liu et al[29]	2022	PubMed	Comparative study of the efficacy, safety, and survival outcomes between HAIC and TACE in liver cancer treatment	Systematic review/meta-analysis
Hu et al[30]	2023	PubMed	Impact of HAIC on the prognosis of patients with liver cancer	Systematic review/meta-analysis
JBI[31]	2023	JBI	Hepatic artery infusion: infusion and/or flushing techniques	Evidence summary
Wang[32]	2024	Wanfang	Perioperative care in hepatic artery infusion chemotherapy	Evidence summary
Chinese Society of Liver Cancer, China Anti-Cancer Association[33]	2021	Wanfang	Chinese expert consensus on HAIC for hepatocellular carcinoma	Expert consensus
Hubei Medical Association, Interventional Medicine Nursing Group[34]	2022	Wanfang	Expert consensus on perioperative nursing strategies for hepatocellular carcinoma treated with transarterial chemoembolization	Expert consensus
Nursing Professional Committee of Strategic Alliance of Technology Innovation for Minimally Invasive Tumor Therapy[35]	2023	Wanfang	Expert consensus on continuous arterial medication and catheter care in hepatic artery infusion chemotherapy	Expert consensus

HAIC = hepatic artery infusion chemotherapy, JBI = Joanna Briggs Institute.

3.2. Results of literature quality assessment

Guideline quality assessment results: After evaluating 1 guideline, the overall assessment was high, leading to its inclusion. See Table 2 for the results of the guideline quality assessment.

Table 2.

Guideline quality assessment results.

Author/institution	The scaled domain score, %
	S&P	Stake. inv.	Rigor dev.	Clarity pres.	Applic	Ed. indep.	≥60% dom.	≥30% dom.	Rec. level (L)	Eval. result
Taiwan Liver Cancer Association[24]	93.06%	68.06%	65.63%	84.72%	46.88%	64.58%	5	6	A	Included

“S&P” refers to scope and purpose; “Stake. inv.” to stakeholder involvement; “Rigor dev.” to rigor of development; “Clarity pres.” to clarity of presentation; “Applic.” to applicability; “Ed. indep.” to editorial independence; “≥60% dom.” indicates domains with scores ≥60%; “≥30% dom.” indicates domains with scores ≥30%.

Systematic reviews and meta-analysis quality assessment results: After evaluating 2 systematic reviews and 4 meta-analyses, the overall assessment was high, resulting in their inclusion. See Table 3 for detailed results.

Table 3.

Quality assessment results for systematic reviews and meta-analyses.

Study	I	II	III	IV	V	VI	VII	VIII	IX	X	XI	Evaluation result
Liu et al[25]	Yes	Yes	Yes	Yes	Yes	Yes	Yes	Yes	Yes	Yes	Yes	Included
Yuanren et al[26]	Yes	Yes	Yes	Yes	Yes	Yes	Yes	Yes	Yes	Yes	Yes	Included
Moran et al[27]	Yes	Yes	Yes	Unclear	Yes	Yes	Yes	Yes	Yes	Yes	Yes	Included
Yan et al[28]	Yes	Yes	Yes	Unclear	Yes	Yes	Yes	Yes	Yes	Yes	Yes	Included
Liu et al[29]	Yes	Yes	Yes	Unclear	Yes	Yes	Yes	Yes	Yes	Yes	Yes	Included
Hu et al[30]	Yes	Yes	Yes	Yes	Yes	Yes	Yes	Yes	Yes	Yes	Yes	Included

(I) Is the evidence question clearly and explicitly formulated? (II) Are the inclusion criteria for the literature appropriate for the evidence question? (III) Is the search strategy appropriate? (IV) Are the databases or resources searched sufficiently comprehensive? (V) Are the criteria used for the literature quality assessment appropriate? (VI) Were there at least 2 reviewers who independently completed the quality assessment? (VII) Were measures taken to reduce error during data extraction? (VIII) Is the method of combining studies appropriate? (IX) Was the potential for publication bias assessed? (X) Are the policy or practice recommendations based on the results of the systematic review? (XI) Is the direction for further research proposed appropriate?

3.3. Quality assessment results for evidence summaries

After evaluating 2 evidence summaries, they were deemed to have a high overall assessment and were included. See Table 4 for the quality assessment results of these evidence summaries.

Table 4.

Quality assessment results for evidence summaries.

Author	I	II	III	IV	V	VI	VII	VIII	IX	X
JBI[31]	Yes	No	No	No	Yes	No	Yes	Yes	No	Yes
Wang[32]	Yes	Yes	Unclear	Yes	Yes	Yes	Yes	Yes	Unclear	Yes

(I) Is the scope and subject matter specific? (II) Is the authorship clear and transparent? (III) Is the review process clear and transparent? (IV) Is the literature search comprehensive? (V) Is the evidence grading clear? (VI) Are the recommendations clear? (VII) Are the references in the recommendations appropriate? (VIII) Are the recommendations timely? (IX) Is there a declaration of conflicts of interest? (X) Is the summary of evidence applicable to the study population assessed?

JBI = Joanna Briggs Institute.

3.4. Quality assessment results for expert consensus

Three expert consensus documents were evaluated and were also considered to have a high overall quality, leading to their inclusion. See Table 5 for the quality assessment results of these expert consensus documents.

Table 5.

Quality assessment results for expert consensus.

Expert group	I	II	III	IV	V	VI	Evaluation result
Chinese Society of Liver Cancer, China Anti-Cancer Association[33]	Yes	Yes	Yes	Yes	Yes	No	Included
Hubei Medical Association, Interventional Medicine Nursing Group[34]	Yes	Yes	Yes	Yes	Yes	No	Included
Nursing Professional Committee of Strategic Alliance of Technology Innovation for Minimally Invasive Tumor Therapy[35]	Yes	Yes	Yes	Yes	Yes	No	Included

(I) Is the source of the opinion explicitly marked? (II) Does the opinion originate from influential experts in the field? (III) Is the viewpoint centered on the benefits to the population studied? (IV) Are the stated conclusions based on analysis results? Is the expression of the opinion logical? (V) Were existing literatures referenced? (VI) Are there inconsistencies with previous literature in the presented viewpoints?

3.5. Evidence summary

We summarized 36 pieces of best evidence, as shown in Table 6. Level 1 evidence accounted for 22.2% (8/36), Level 2 for 2.8% (1/36), Level 3 for 2.8% (1/36), and Level 4 for 8.3% (3/36). Level 5 evidence constituted 63.9% (23/36), indicating that many recommendations are supported primarily by expert opinion or consensus and should therefore be interpreted cautiously and adapted to local protocols. Appraisal results across evidence types were not treated as directly comparable scores because each instrument emphasizes different methodological domains. The strength of support for each nursing recommendation is presented using the JBI levels of evidence (2014) in the evidence summary below (Table 7).

Table 6.

Distribution of evidence levels.

Evidence category	n	Level 1	Level 2	Level 3	Level 4	Level 5
HAIC puncture care	8	0 (0.0%)	0 (0.0%)	0 (0.0%)	0 (0.0%)	8 (100.0%)
HAIC medication care	15	4 (26.7%)	1 (6.7%)	0 (0.0%)	1 (6.7%)	9 (60.0%)
Catheter complication prevention and management	10	4 (40.0%)	0 (0.0%)	0 (0.0%)	2 (20.0%)	4 (40.0%)
Catheter removal care	3	0 (0.0%)	0 (0.0%)	1 (33.3%)	0 (0.0%)	2 (66.7%)
Total	36	8 (22.2%)	1 (2.8%)	1 (2.8%)	3 (8.3%)	23 (63.9%)

Table 7.

Summary of evidences.

Evidence category		Evidence content	Evidence level
HAIC puncture care		1. Recommended arterial routes for catheterization are the femoral and radial arteries[35]	5b
		2. Arterial pulse assessment: Evaluate arterial pulse based on surgical access route for pre- and post-surgery comparison[32]	5b
		3. Assess skin condition around catheter site prior to catheterization[31]	5b
		4. Recommend using the Seldinger technique for percutaneous catheter placement; prepare materials prior to puncture[35]	5b
		5. Catheter fixation methods include transparent dressing, self-adhesive surgical dressing, catheter fixation strips; radial artery catheterization recommends using a radial artery catheter fixation sleeve, which also provides warmth[35]	5b
		6. Post-catheterization, use 5–10 mL of 100 U/mL heparin saline for catheter sealing[35]	5b
		7. Properly label high-risk catheters[35]	5b
		8. After catheter placement, perform imaging to confirm correct catheter position before returning to the ward[35]	5b
HAIC medication care	Preparation before administration	9. Nurse preparation: Correctly wear sterile gloves and protective clothing, and prepare eye and face protection[31]	5b
		10. Equipment preparation: Therapy cart, sterile dressing tray, medication devices, cytotoxic waste bags, and trash cans[31]	5b
	Nursing during administration	11. Prior to medication, strictly implement bedside double-check system[35]	5b
		12. Check the functionality of the drive device and the expiration date of the medication cartridge, install the cartridge on the drive device, ensure tight connections, correct parameter settings, lock the screen, and start[35]	5b
		13. Strictly adhere to aseptic techniques[31]	5b
		14. During continuous medication, continuously monitor patient’s consciousness, vital signs, abdominal signs, intake and output; condition of the catheter puncture site and exposed parts; color and temperature of the limb with the catheter, arterial pulse, etc[35]	1c
		15. Assess input and remaining medication volume hourly to ensure alignment with timing[31,35]	4d
		16. Promptly address any alarms from the chemotherapy pump[35]	5b
		17. Instruct patients with femoral artery access to rest in bed primarily, elevate the head of the bed <30°, and turn every 2–3 h; avoid extensive movement of the limb with the catheter, instruct in ankle pump exercises to promote blood return and prevent deep vein thrombosis[33,35]	1c
		18. For patients with radial artery access, it is recommended to place the forearm on a soft pillow to promote venous return[35]	2c
		19. Actively listen to patients’ feelings about catheter placement and enhance communication, strengthen education to improve patient compliance[35]	5b
		20. Monitor for systemic complications including: fever, rash, itching, nausea or vomiting, diarrhea, decreased neutrophils, deteriorating liver function, anemia, and thrombocytopenia[25–28,30]	1b
		21. Hydration during medication: Intake ≥3000 mL/d on days 1–2 of HAIC treatment; assist patients with drinking according to a hydration plan, accurately record urine output, >2000 mL/d urine output in the 1st 24 h postoperation[34]	1c
		22. Follow medical orders to monitor laboratory test results: complete blood count, liver and kidney functions, coagulation profiles[35]	5c
		23. Adhere to standards for nursing records and handover[31]	5b
HAIC catheter complication prevention and management	Catheter displacement	24. Displacement of the catheter tip can lead to the extravasation of chemotherapy drugs, manifesting as abdominal pain, nausea, vomiting, etc. Nurses should promptly identify and inform the physician; if catheter displacement is suspected, immediately stop the infusion of drugs and perform imaging tests.[35]	1d
		25. Confirm catheter displacement, remove promptly[35]	1d
	Catheter obstruction	26. In the event of catheter obstruction, use a 10 mL syringe to gently aspirate with 5000 U/mL urokinase solution, repeating every 5–10 min until the catheter is clear[35]	4c
		27. If arterial narrowing or thrombosis is confirmed, promptly remove the catheter[35]	4c
	Catheter-related infections	28. Preventive measures include skin preparation before puncture, sterile operation, careful observation of the puncture site for signs of infection during medication, and using antibiotics when necessary[35]	1c
		29. In cases of severe infection, follow medical advice to use antibiotics or remove the catheter[35]	5b
	Arterial spasm or occlusion	30. Arterial spasms often occur in the radial artery; it is recommended to relieve symptoms of pain, numbness, and swelling through active movement and massage[35]	5b
		31. Adjusting the compression intensity based on oxygen saturation can help reduce the incidence of radial artery occlusion without increasing the risk of bleeding[35]	1c
	Unplanned catheter removal	32. Assess the patient’s consciousness, psychological state, and any accompanying symptoms such as pain, fever, or skin itching, as well as any history of previous catheter removals, to identify high-risk groups for unplanned catheter removal[35]	5b
		33. In cases of unplanned catheter removal, perform a dual assessment of the integrity of the dislodged catheter[35]	5b
Catheter removal care		34. After all medication has been infused and the line flushed, a nurse assists the physician in removing the catheter using aseptic techniques. The method for compressing the puncture site to stop bleeding is the same as that used after arterial chemoembolization[35]	3c
		35. After removing a radial artery catheter, avoid re-puncturing or measuring blood pressure on the affected side, do not rub the puncture site for 1 wk, and avoid lifting heavy objects for 4 wk[34]	5b
		36. After removing a femoral artery catheter, assist the patient in getting out of bed within 6–12 h[34]	5b

4. Discussion

4.1. Optimizing HAIC catheter placement and catheter care

4.1.1. Strategic catheter selection and access site choice

Successful HAIC administration requires strategic catheter placement decisions that balance procedural efficacy with patient safety. The current HAIC protocol, involving oxaliplatin, calcium folinate, and fluorouracil administered tri-weekly over a minimum of 4 cycles,^[33,36] presents unique challenges due to the necessity for repeated catheter repositioning at each session.

Single-use arterial catheterization has emerged as the preferred approach over hepatic arterial port installation, primarily due to its procedural adaptability and reduced risk of port-related complications.^[11,37] This approach aligns with the Japanese Society of Interventional Radiology clinical practice guidelines for hepatic arterial infusion chemotherapy. This preference introduces the challenge of selecting optimal vascular access for each treatment session. The choice between femoral and radial arterial access should be individualized based on patient-specific conditions and procedural requirements.

4.1.2. Pre-procedural vascular and dermatological assessment

For radial access candidates, pre-procedural evaluation using the Allen test provides a straightforward and effective assessment of radial and ulnar artery patency and collateral circulation.^[38] The reliability of this bedside test depends on rigorous adherence to standardized protocols, with supplementary diagnostics such as Doppler ultrasound or arteriography recommended when clinical uncertainty exists.^[36]

Beyond vascular evaluation, a thorough assessment of pericatheter skin conditions is essential to minimize infection and complication risks. This assessment should systematically evaluate skin color, temperature, integrity, and signs of infection to ensure puncture site suitability. The integration of vascular and dermatological assessments reflects a holistic approach to patient selection and risk stratification.

4.1.3. Insertion technique and stabilization strategies

The Seldinger technique is recommended as the standard insertion method, offering advantages in simplicity, minimal invasiveness, and high success rates while reducing both immediate surgical risks and subsequent catheter-related complications.^[36] Post-insertion stabilization represents a critical but often underemphasized aspect of catheter care. Radial artery catheterization carries a specific risk of arterial spasm due to smooth muscle stimulation during catheter manipulation. Radial artery spasm manifests as arterial narrowing and reduced lumen size, complicating blood flow and instrument passage.^[39] The use of specialized radial artery catheter fixation sleeves addresses this challenge through dual mechanisms: effective catheter stabilization and provision of thermal comfort, both contributing to reduced spasm incidence and enhanced patient tolerance.

4.1.4. Catheter identification and safety marking

Given the high-risk nature of arterial catheters, proper identification marking serves as a fundamental safety measure. Clear catheter labeling enables healthcare personnel to rapidly recognize catheter type, location, and intended purpose, thereby reducing mishandling risks and enhancing overall patient safety. This seemingly simple intervention reflects broader principles of high-reliability healthcare systems, where clear communication and visual cues prevent adverse events.

4.2. Ensuring patient safety and comfort during continuous HAIC administration

4.2.1. Process standardization and monitoring

As HAIC involves high-risk procedures and chemotherapy administration, safeguarding patient safety through process standardization is critical.^[40] A double-check of personnel and equipment should occur before each session.^[41] Continuous monitoring includes vital signs, abdominal indicators, catheter position, and equipment functionality. Multi-parameter surveillance enables rapid intervention when complications arise.

4.2.2. Patient positioning and systemic toxicity management

Positioning strategy depends on the access site. Femoral catheter patients should restrict major leg movements to prevent displacement. Radial access patients should have the forearm elevated on a cushion with the wrist flexed 10° to 15° to facilitate venous return.^[42] HAIC causes systemic complications, including fever, rash, pruritus, nausea, vomiting, diarrhea, neutropenia, anemia, and hepatic dysfunction.^[43] Routine monitoring of complete blood counts, liver and kidney function, and coagulation profiles enables early toxicity detection and treatment adjustment. Laboratory surveillance should follow standardized intervals to establish trends.

4.2.3. Prevention of contrast-induced nephropathy

Contrast-induced nephropathy ranks as the 3rd leading cause of hospital-acquired acute kidney injury.^[44] Prevention requires meticulous hydration: fluid intake ≥3000 mL/d and urine output >2000 mL/d during the 1st 48 hours post-catheterization. Evidence-based protocols recommend intravenous 0.9% normal saline at 1 mL/kg/h for 6 to 12 hours pre-procedure, continuing post-procedure.^[45] Hydration targets may require adjustment based on cardiac function, baseline renal status, and fluid tolerance.

4.2.4. Patient education and psychological support

Patient comfort and psychological preparation significantly impact adherence. Active listening to patient experiences provides insights complementing objective monitoring. Structured education with information brochures provided pre-procedure significantly reduces procedural anxiety and fear.^[46] Education regarding expected sensations, warning signs, and positioning rationale enhances cooperation and reduces anxiety. This communication improves treatment adherence across multi-cycle regimens.^[42] Comprehensive documentation and shift handovers ensure treatment continuity, enable pattern recognition, and prevent information loss leading to errors.^[44]

4.3. Enhancing arterial catheter care to minimize complication risks

4.3.1. Monitoring for mechanical and infectious complications

Effective management of catheter-related complications directly impacts treatment completion rates and patient outcomes during HAIC administration.

Three primary complications require systematic monitoring during HAIC: catheter displacement, blockage, and infection. Displacement compromises drug delivery precision and may require repositioning. Blockage interrupts infusion and risks incomplete dosing. Infection remains a concern despite lower rates with single-use systems compared to implanted ports. Early recognition through regular assessment of catheter function, flow rates, and insertion site appearance enables timely intervention.

4.3.2. Management of radial artery spasm and unplanned removal risks

Radial artery spasm occurs more frequently than femoral spasm due to smaller vessel size. Management emphasizes non-pharmacological approaches: active limb movement and gentle forearm massage promote vasodilation. Compression adjustment, guided by oxygen saturation monitoring, balances hemostasis against radial artery occlusion risk without increasing bleeding. Unplanned removal causes treatment interruption and necessitates re-catheterization with associated risks. High-risk patients can be identified through assessment of consciousness, mental status, pain control, fever, pruritus, and prior removal history. Recognition enables targeted interventions, including enhanced education, increased monitoring, and family involvement.^[47]

4.3.3. Post-removal protocols and discharge care

When unplanned removal occurs, immediate assessment must verify catheter integrity and evaluate the puncture site. Re-catheterization decisions should weigh treatment urgency against complication risks. Post-removal protocols differ by access site. Femoral access requires 6 to 12 hours of assisted ambulation following sheath removal due to larger vessel size and deeper location. Radial access permits immediate ambulation due to superficial location, enabling direct compression.

Regardless of site, patients should avoid re-puncture or blood pressure measurement on the affected limb, manipulation of the puncture site for 1 week, and heavy lifting for 4 weeks.

4.4. Implications for nursing practice and research

This synthesis of 36 evidence-based recommendations provides a framework for HAIC nursing care spanning the full procedural continuum.

4.4.1. Standardization and protocol implementation

Translating these recommendations into consistent bedside practice requires adaptation to diverse clinical contexts. Standardized protocols offer particular value in institutions with moderate HAIC procedure volumes, where consistent protocols maintain competency across distributed provider experience. Successful implementation demands alignment with existing workflows, electronic health record systems, and nursing staffing models.

4.4.2. Educational requirements and resource allocation

The technical complexity of HAIC procedures necessitates structured nursing education addressing vascular assessment skills, early complication recognition, risk stratification, and patient communication. Beyond education, institutions must consider resource allocation for equipment, simulation-based training, and potentially specialized credentialing processes.

4.5. Recommendations for practice

1. Use a standardized protocol for puncture site care and catheter fixation to reduce displacement.

2. Assess limb perfusion and catheter patency regularly and document findings.

3. Apply a double-check process for HAIC medication preparation and infusion pump settings.

4. Monitor infusion lines and pump alarms at scheduled intervals to prevent interruption or leakage.

5. Use a structured checklist to screen for early signs of bleeding, infection, thrombosis, occlusion, and pump malfunction, with clear escalation steps.

6. Provide focused patient education on activity restriction, catheter protection, and symptom reporting.

7. Standardize catheter removal criteria and post-removal monitoring to prevent bleeding and delayed complications.

8. Support implementation through staff training and by integrating key steps into routine workflow and EHR.

4.6. Limitations

This review has several limitations. First, the search was restricted to Chinese and English databases, potentially overlooking relevant studies in other languages. Second, the methodological quality of the included evidence was heterogeneous. While systematic reviews provided strong evidence for medication management, specific nursing procedures relied heavily on expert consensus (level 5 evidence). This reliance on expert opinion implies a lower certainty of evidence for procedural recommendations. Finally, the specific nursing protocols varied across the included guidelines, reflecting a lack of global standardization.

5. Conclusion

This evidence summary synthesizes 36 recommendations for HAIC nursing care and provides an evidence-informed framework to support standardized bedside practice. The study suggests that safe HAIC nursing care requires standardized vascular assessment and catheter placement and fixation. It also requires continuous monitoring during infusion and timely prevention and management of catheter-related events such as displacement, occlusion, or thrombosis, and infection. Implementation should be adapted with local validation, and future studies should compare catheter care bundles in multicenter prospective designs or pragmatic RCTs.

Acknowledgments

We would like to express our gratitude to all the participants in the study.

Author contributions

Conceptualization: Mingyan Shen.

Data curation: Zuxin Shi, Linqiu Han, Tian He.

Formal analysis: Zuxin Shi, Linqiu Han.

Investigation: Zuxin Shi, Linqiu Han, Tian He.

Methodology: Zuxin Shi.

Supervision: Mingyan Shen.

Validation: Tian He.

Writing – original draft: Zuxin Shi.

Writing – review & editing: Mingyan Shen.