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Difficult IV Access
Patients with difficult intravenous access (DIVA) present a growing challenge to nurses. Learn more about the special consideration needed when selecting vascular access devices and preparing for insertion for these types of patients.
Difficult IV access patients can experience delays in care due to the inability to establish vascular access in a timely manner.1 Key clinical workflows such a obtaining blood samples for lab testing, delivering analgesics, antibiotics, blood products or fluids often rely on intravenous access. Obesity, edema, or history of intravenous drug use have been identified as signs of DIVA.1 Children are also known to experience difficulty in establishing vascular access.2
DIVA patients experience multiple challenges during infusion therapy:
Visible and palpable veins can be harder to see in children with DIVA. Multiple attempts at peripheral IV insertion can be traumatic to children.2 This challenge is compounded in children with obesity.4
Using the conventional method for peripheral IV insertion involves clearly identifying visible and palpable veins. However, this can be challenging for patients with darker skin tones. Various skin colour scales have been created to help healthcare professionals identify when they should use vein visualization technology for IV insertions.
Obesity is a contributing factor to difficult IV access. This is likely because the higher presence of subcustaneous fat makes it more difficult to visualize and palpate veins.3
Patient's whose vascular system is accessed frequently can become DIVA patients.3 This could be individuals with chronic illnesses, IV drug users or chemotherapy patients. Constant needle sticks in the vein can result in venous depletion as they are no longer able to withstand the infusion therapy. This can occur from the common challenges of peripheral IV catheters such as: phlebitis, infiltration, occlusion and/or dislodgement. When multiple peripheral IV insertions are conducted, the risk of failure of each subsequent catheter is progressively increase.5
Ultrasound guidance provides a real time 2-D image of blood vessels that appear as compressible circular structures.6
Vein Visualization in Different Skin Tones
In a multicenter validation study, it was determined that using ultrasound guidance for peripheral IV insertions mitigated the challenges that a patient's skin may cause in relation to difficult IV access.7
Vein Visualization in Pediatric Population
In a pediatric study compared the success rate of placing short peripheral catheters to longer peripheral catheters. There was a 100% success rate of placing long peripheral catheters in a pediatric patient using ultrasound guided insertions.2 The number of attempts before successful placement of a short peripheral catheter in a pediatric patient was significantly higher.2
In routine clinical practice of peripheral IV insertions using the conventional method, DIVA patients are identified after multiple failed attempts to insert a catheter which can result in multiple catheter restarts.7 Identifying a DIVA patient before the first IV attempt can possibly lower the incidence of a failed first attempt, improve patient outcomes and reduce healthcare costs due to greater hospital efficiency of staff time and equipment.7
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1. Shokoohi H, Loesche MA, Duggan NM, Liteplo AS, Huang C, Al Saud AA, McEvoy D, Liu SW, Dutta S. Difficult intravenous access as an independent predictor of delayed care and prolonged length of stay in the emergency department. J Am Coll Emerg Physicians Open. 2020 Aug 19;1(6):1660-1668. doi: 10.1002/emp2.12222. PMID: 33392574; PMCID: PMC7771794.
2. Paldini A. et al. Ultrasound-guided placement of long peripheral cannulas in children over the age of 10 years admitted to the emergency department: a pilot study. BMJ Paediatrics Open. (2018) https://doi.org/10.1136/bmjpo-2017-000244
3. Rodriguez-Calero, M. A. et al. Defining risk factors associated with difficult peripheral venous cannulation: A systematic review with meta-analysis. Heart & Lung. (2020) https://doi.org/10.1016/j.hrtlng.2020.01.009
4. Nafiu, O. O. MD, FRCA. et al. Comparing peripheral venous access between obese and normal weight children. Pediatric Anesthesia. (2010) https://doi.org/10.1111/j.1460-9592.2009.03198.x
5. Helm, R. E. MD. et al. Accepted but Unacceptable: Peripheral IV Catheter Failure. The Art and Science of Infusion Nursing. (2015) https://doi.org/10.1097/NAN.0000000000000100
6. Crowley, M., MSN, RN, CEN, MICN. et al. Emergency Nursing Resource: Difficult Intravenous Access. Emergency Nurse Journal (2012) https://doi.org/10.1016/j.jen.2012.05.010
7. Van Loon FH, Van Hooff LW, de Boer HD, Koopman SS, Buise MP, Korsten HH, Bouwman AR. The modified A-DIVA scale as a predictive tool for prospective identification of adult patients at risk of a difficult intravenous access: A multicenter validation study. Journal of Clinical Medicine. 2019;8(2):144-156
