Management of difficult intravenous access: a qualitative review

Abstract

Establishing peripheral intravenous access (PIV) is one of the most ubiquitous and crucial steps in managing critically ill patients. Yet only 74% of first attempts during emergency resuscitation in adults [1] are successful and this falls to an even-more-dismal 33% in difficult intravenous access (DIVA) patients. [2] A perennial challenge faced by clinicians, DIVA impacts patient outcomes adversely by causing downstream delays in both diagnoses (difficulty in obtaining blood specimens and administering intravenous contrast for advanced imaging) and therapy (provision of parenteral fluids, blood products or drug administration to facilitate procedures such as sedation or rapid-sequence intubation). [3] Failed cannulation attempts often cause patient and clinician alike considerable frustration and distress and may lead to complications like thrombophlebitis, infection and haematoma. [4] Moreover, time-to-cannulation averages 2.5-13.0 min for most patients but can take up to 30 min to hours in DIVA cases. [5] As DIVA patients tend to distract disproportionately more time and attention of the attending emergency physicians, this inevitably compromises the care of other patients.Although there is no consensus or universallyaccepted definition, DIVA is commonly defined as either two or more failed attempts by an experienced operator using traditional landmark-based methods BAcKGRound: A perennial challenge faced by clinicians and made even more relevant with the global obesity epidemic, difficult intravenous access (DIVA) adversely impacts patient outcomes by causing significant downstream delays with many aspects of diagnoses and therapy. As most published DIVA strategies are limited to various point-of-care ultrasound techniques while other "tricks-of-the-trade" and pearls for overcoming DIVA are mostly relegated to informal nonpublished material, this article seeks to provide a narrative qualitative review of the iterature on DIVA and consolidate these strategies into a practical algorithm. MEtHodS:We conducted a literature search on PubMed using the keywords "difficult intravenous access", "peripheral vascular access" and "peripheral venous access" and searched emergency medicine and anaesthesiology resources for relevant material. These strategies were then categorized and incorporated into a DIVA algorithm. RESuLtS:We propose a Vortex approach to DIVA that is modelled after the Difficult Airway Vortex concept: starting off with standard peripheral intravenous cannulation (PIVC) techniques, progressing sequentially on to ultrasound-guided cannulation and central venous cannulation and finally escalating to the most invasive intraosseous access should the patient be in extremis or should best efforts with the other lifelines fail. concLuSIon: DIVA is a perennial problem that healthcare providers across various disciplines will be increasingly challenged with. It is crucial to have a systematic stepwise approach such as the DIVA Vortex when managing such patients and have at hand a wide repertoire of techniques t...

A 94-year-old patient with severe burns: a case report

“…ICU patients suffer from ICU-acquired weakness, cognitive impairment, and psychological disturbance due to long-term bed rest, fixation, and mechanical ventilation. [5,6] EMR is believed to avoid these complications and alleviate the adverse effects of postintensive care syndrome. Compared with other patients, acute critical burn patients have unique needs for analgesia, sedation, and skin grafting, which makes EMR-targeted measures more difficult to implement.…”

Pilot study of peripheral internal jugular venous catheters on a hospitalist‐run medicine procedure service

“…Difficult intravenous access (DIVA), whether due to obesity, edema, vasoconstriction, hypotension, poor vein quality, “save‐arm” precautious, or other etiologies, is a common problem confronting providers caring for hospitalized patients. While a number of interventions for establishing intravenous (IV) access for such patients have been described, 1 nontunneled central venous catheters (CVCs) are often a default access option for DIVA patients. However, CVCs have known complications, including peri‐procedural trauma and central line‐associated bloodstream infection (CLABSI) 2 .…”

Subcutaneous vein display device based on dual wavelength LED source

“…In clinical practice, intravenous infusion is one of the most common treatment methods. It is very important to quickly and accurately search for venous vessels during infusion at night or in dark light conditions and in emergency situations [1][2][3][4][5][6] .However, for children, the elderly, and patients whose veins are not easily exposed, it is difficult for medical staff to quickly and accurately find veins and successfully puncture them.Repeated needling not only brings pain and irritation to patients, but also risks the repeated stimulation of needles to induce venous inflammation, which will also lead to the failure of venous puncture and become the fuse of medical and patient accidents. Especially in pediatrics, because the blood vessels of children are very small and difficult to locate accurately, increasing the number of punctures is easy to cause disputes between doctors and patients.…”