What is the term for difficult peripheral intravenous (IV) access?

Difficult Peripheral IV Access (DIVA)

Definition and Terminology

The accepted term is "Difficult Intravenous Access" (DIVA), defined as when a clinician has two or more failed attempts at peripheral IV access using traditional techniques, physical examination findings suggest DIVA (no visible or palpable veins), or the patient has a documented history of DIVA 1.

Clinical Recognition

The prevalence of DIVA ranges from 6% to 87.7% depending on the population and definition used 1. Key identifying features include:

• Two or more failed cannulation attempts using standard technique 1
• Absence of visible or palpable veins on physical examination 1
• Patient-reported history of difficult access 1
• Risk factors including obesity, history of injection drug use, and venous depletion from repeated access attempts 2

Management Algorithm by Expected Duration

Short-Term Access (≤5 days)

For patients requiring 5 or fewer days of access, the approach depends on infusate compatibility 3:

• Peripherally compatible infusates: Use ultrasound-guided peripheral IV catheters as first-line 3
• Non-peripherally compatible infusates: PICC placement appropriateness is uncertain; decisions should be individualized after discussing risks and benefits 3

Medium-Term Access (6-14 days)

For 6-14 days of expected use, ultrasound-guided peripheral IV catheters or midline catheters are preferred over PICCs 3. Midline catheters (10-20 cm length) inserted into upper arm veins provide effective access for this duration 3, 4.

Longer-Term Access (≥15 days)

• 15-30 days: PICCs are appropriate 3
• ≥31 days: Tunneled catheters or implanted ports become appropriate options 3

Ultrasound-Guided Technique

Ultrasound guidance significantly reduces the perceived difficulty of IV access in DIVA patients 5. In one study, 80% of patients rated as "very hard sticks" without ultrasound had their difficulty reduced to "easy" or "very easy" with ultrasound guidance 5.

Preferred Vein Selection

The basilic vein is the first-choice target for ultrasound-guided access due to its superficial location and larger diameter 4. The hierarchy is:

1. Basilic vein (preferred) 4
2. Brachial vein (second choice, but higher risk of arterial/nerve injury) 4
3. Cephalic vein (avoid due to higher thrombosis rates and technical difficulty) 4

Emergency Alternatives

When IV access cannot be obtained in emergency situations, intraosseous (IO) access is the preferred alternative route 6. IO access provides drug delivery comparable to peripheral IV access and can be established faster than central venous access 6. Preferred insertion sites are the tibia and humerus 6.

Critical Special Populations

Chronic Kidney Disease

In patients with stage 3b CKD or greater (eGFR <45 mL/min), avoid placing any devices (PICCs, midline catheters) in arm veins to preserve vessels for future hemodialysis access 3, 4. For these patients requiring short-term access (≤5 days), place peripheral IVs in the dorsum of the hand, avoiding forearm veins 3.

Lymphedema

Avoid insertion in limbs with lymphedema except in acute situations due to increased infection risk 3, 4.

Common Pitfalls

• Do not routinely change peripheral cannulae at 72-96 hours—this practice is not advocated 3, 4
• Use the smallest practical cannula size to minimize vein trauma 3, 4
• Avoid repeated blind attempts—ultrasound-guided peripheral IVs prevent unnecessary central line placement in 93% of DIVA patients 2
• Recognize that 47% of ultrasound-guided IVs fail within 24 hours, most commonly due to infiltration, but they still prevent the need for central access in the majority of cases 2