CLINICAL PRACTICE
GUIDELINE:
Difficult Intravenous Access
In emergency department patients with known or suspected
difficult intravenous access, does ultrasound-guided,
intraosseous, subcutaneous rehydration therapy, warming,
or alternative methods improve intravenous access
with fewer attempts, less pain, and/or improved patient
satisfaction as compared to traditional techniques?
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CLINICAL PRACTICE GUIDELINE:
Difficult Intravenous Access
Table of Contents
Background and Significance__________________________________________________________________3
Methodology_______________________________________________________________________________3
Summary of Literature Review________________________________________________________________5
Description of Decision Options/Interventions and the Level of Recommendation________________________12
References________________________________________________________________________________13
Authors__________________________________________________________________________________16
Acknowledgments__________________________________________________________________________16
Appendix 1: Evidence Table__________________________________________________________________17
Appendix 2: Other Resources Table____________________________________________________________32
Appendix 3: Study Selection Flowchart and Inclusion/Exclusion Criteria_______________________________37
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CLINICAL PRACTICE GUIDELINE:
Difficult Intravenous Access
Background/Significance
Establishing vascular access is one of the most common procedures carried out in the emergency department (ED) and a high
priority for the care of critically ill and unstable patients. The patient’s condition often plays a role in the likelihood of attaining
vascular access. Conditions associated with difficult vascular access include obesity, chronic illness, hypovolemia, intravenous (IV)
drug abuse, and vasculopathy (Blavias & Lyon, 2006; Chinnock, Thornton, & Hendey, 2007; Costantino, Parikh, Satz, & Fojtik,
2005; Doniger, Ishimine, Fox, & Kanegaye, 2009; Heinrichs, Fritze, Vandermeer, Klassen, & Curtis, 2012; Miles, Salcedo, & Spear,
2011; Nafiu et al.,2010; Sebbane et al., 2013). Children under the age of two years, particularly young infants, are also more likely to
present with difficult vascular access (Chapman, 2011; Heinrichs et al., 2012).
Success rate and time to vascular cannulation are crucial to the optimal resuscitation of a critically-ill patient. This can be a
challenging to even the most experienced emergency nurse. Patients with difficult IV access are frequently subjected to repeated
attempts by multiple practitioners due to failed IV attempts and are more likely to experience treatment delays (Witting, 2012).
Failure rates of emergent IV access vary in the literature. Leidel et al. (2009) identified a failure rate ranging from 10 to 40%,
which is consistent with the findings from a study by Witting (2012) that found 39% of study participants had a failed first time
attempt at IV access. The average time requirement for peripheral IV cannulation is reported at 2.5 to 16 minutes, with difficult
IV access requiring as much as 30 minutes (Leidel et al., 2012). Witting (2012) found that delays in care were significant when IV
access difficulty requires physician intervention with physician time devoted to obtaining IV access ranging from 22 to 57 minutes.
Katsogridakis, Seshadri, Sullivan, and Waltzman (2008) identified success rates in multiple attempts for admitted patients at a
children’s hospital ranges from 23% for physicians, 44% for nurses to 98% for IV nurse clinicians. The number of attempts at IV
cannulation for the pediatric patient ranges from 1 to 10 attempts (Katsogridakis et al., 2008). Utilization of anatomic landmarks
for peripheral IV access holds a 90% success rate (Costantino et al., 2005).
Central venous catheterization (CVC) is a common alternative approach to attain cannulation in patients with difficult venous
access. CVC cannulation provides vascular access for fluid resuscitation, and additionally allows for hemodynamic monitoring.
Unfortunately, CVC line placement is not without risk with 5-15% of lines being associated with immediate or delayed complications
(Au, 2012). Most common among these complications are venous thrombosis, arterial puncture, catheter associated bloodstream
infection, and pneumothorax (Leidel et al., 2009). Another concern with CVC placement is that it requires interruption of
cardiopulmonary resuscitation (Leidel et al., 2012). Given the time required to establish a central venous catheter, the increased
risk to the patient, and the skill required of the provider, other alternatives for vascular access are often desirable.
A delay in establishing vascular access can result in a delay in the administration of a fluids and/or medications. Patients frequently
experience delays in diagnosis and initiation of treatment. In addition, multiple attempts at attaining vascular access result in
frustration and a loss of productivity by the treating team (Rauch, Dowd, Eldridge, Mace, & Schears, 2009).
Methodology
This CPG was created based on a thorough review and critical analysis of the literature following ENA’s Requirements for the
Development of Clinical Practice Guidelines. Via a comprehensive literature search, all articles relevant to the topic were identified.
The articles reviewed to formulate the recommendations in this CPG are described in Appendix 1. The following databases were
searched: PubMed, Google Scholar, CINAHL, Cochrane - British Medical Journal, Agency for Healthcare Research and Quality,
and the National Guideline Clearinghouse. Searches were conducted using the search terms “difficult intravenous access,” “tools
intravenous access,” “heat,” “nitroglycerin,” “tourniquet,” “ultrasound,” “light,” “illumination,” “subcutaneous rehydration therapy,”
and “hypodermoclysis,” using a variety of different search combinations. Searches were limited to English language articles on
human subjects from January 2003 - October 2011. A 2015 update on this CPG searched for articles published from 2011-2015 and
also included the keywords “interosseous”, “infrared”, and “ultrasound guided”. In addition, the references of the selected articles
were scanned for pertinent research findings. Meta-analyses, systematic reviews, and research articles from emergency department
settings, non-ED settings, position statements and guidelines from other sources were reviewed (Appendix 3). Clinical findings and
levels of recommendations regarding patient management were made by the CPG Committee according to ENA’s classification of
levels of recommendation for practice (Table 1).
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CLINICAL PRACTICE GUIDELINE:
Difficult Intravenous Access
Table 1. Levels of Recommendation for Practice
Level A recommendations: High
• Reflects a high degree of clinical certainty
• Based on availability of high quality level I, II and/or III evidence available using Melnyk & Fineout-Overholt grading system
(Melnyk & Fineout-Overholt, 2005)
• Based on consistent and good quality evidence; has relevance and applicability to emergency nursing practice
• Is beneficial
Level B recommendations: Moderate
• Reflects moderate clinical certainty
• Based on availability of Level III and/or Level IV and V evidence using Melnyk & Fineout-Overholt grading system
(Melnyk & Fineout-Overholt, 2005)
• There are some minor or inconsistencies in quality evidence; has relevance and applicability to emergency nursing practice
• Is likely to be beneficial
Level C recommendations: Weak
• Level V, VI and/or VII evidence available using Melnyk & Fineout-Overholt grading system (Melnyk & Fineout-Overholt,
2005) - Based on consensus, usual practice, evidence, case series for studies of treatment or screening, anecdotal evidence
and/or opinion
• There is limited or low quality patient-oriented evidence; has relevance and applicability to emergency nursing practice
• Has limited or unknown effectiveness
Not recommended for practice
• No objective evidence or only anecdotal evidence available; or the supportive evidence is from poorly controlled or
uncontrolled studies
• Other indications for not recommending evidence for practice may include:
◦◦ Conflicting evidence
◦◦ Harmfulness has been demonstrated
◦◦ Cost or burden necessary for intervention exceeds anticipated benefit
◦◦ Does not have relevance or applicability to emergency nursing practice
• There are certain circumstances in which the recommendations stemming from a body of evidence should not be rated as
highly as the individual studies on which they are based. For example:
◦◦ Heterogeneity of results
◦◦ Uncertainty about effect magnitude and consequences,
◦◦ Strength of prior beliefs
◦◦ Publication bias
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CLINICAL PRACTICE GUIDELINE:
Difficult Intravenous Access
Summary of Literature Review
DIFFICULT INTRAVENOUS ACCESS: GENERAL INFORMATION
Difficult intravenous (IV) access is defined as multiple attempts and/or the anticipation of special interventions being required to
establish and maintain peripheral venous access (Kuensting, DeBoer, Holleran, Shultz, & Steinmann, 2009). Gregg, Murthi, Sisley,
Stein, and Scalea (2010) identified predictive factors for difficult IV access as edema, obesity, and history of IV drug use. While the
literature regarding factors associated with difficult IV access in adults is limited, included are chemotherapy, diabetes, and multiple
prior hospitalizations (Lapostolle et al., 2007). It is further noted by Lapostolle et al. (2007), that venous cannulation at the hands of
a more experienced emergency care provider was associated with an increased success rate. Smaller caliber IV catheters were more
commonly associated with cannulation failure (Lapostolle et al., 2007). This finding was postulated to be due to the choice of the
person inserting the IV catheter, and the anticipated ease or difficulty of insertion.
The literature on difficult IV access in children is more robust; however, there were only a few randomized controlled trials
conducted in the ED setting identified in the literature search. In the pediatric medical-surgical setting, Lininger (2003) identified
that 53% of peripheral IV attempts (N = 249) were successful on the first attempt, with an increase to 91% within four attempts. This
led to the implementation of a standard of practice at that institution that specified no more than four attempts at IV cannulation were
to be made by RN staff. The average time for venous access in the pediatric patient is 33 minutes (Rauch et al., 2009). Nafiu et al.
(2010) studied the relationship between body mass index (BMI) and the ease of venous access in children ages 2 to 18 years. Obese
children (BMI greater than the 95th percentile) were more likely to have a failed attempt at first cannulation than their lean controls
and more likely to have two or more attempts at cannulation (Nafiu et al., 2010). Larsen and colleagues (2010) conducted a study
to evaluate the relationship between nurse experience and competency and pediatric IV success rates. The researchers conducted a
study with 592 pediatric patients in two pediatric hospitals and found that nurse experience was not a predictor of success; however,
time of day, anticipated difficult IV access, and cooperation level of the child were most predictive of success (Larsen et al., 2010).
In 2008, Yen, Reigert and Gorelick studied IV access with an objective of developing a tool to predict difficult IV access in children.
In a study of 615 children, a 4-variable difficult IV access (DIVA) score was created using 3 points for prematurity, 3 points for
younger than 1 year, 1 point for 1-2 years of age, 2 points for vein not palpable, and 2 points for vein not visible (Yen et al., 2008).
Subjects with a difficult IV access score of 4 or greater were more than 50% likely to have failed IV cannulation on the first attempt.
A study published by Riker, Kennedy, Winfrey, Yen, and Dowd (2011) validated and refined the difficult IV access score prediction
tool demonstrating that age, vein palpability and visibility are reliable predictors of difficult IV access in children.
ULTRASOUND-GUIDED INTRAVENOUS ACCESS
Ultrasound guidance for venous access was initially studied for central access and shown to increase success rates and decrease
complications (Costantino et al., 2005; Stein, George, River, Hebig, & McDermott, 2009). The use of ultrasound-guided techniques
to gain venous access is widely studied in the ED setting for both adult and pediatric populations. Ultrasound guidance provides real
time 2-D image of blood vessels that appear as compressible circular structures (Walker, 2009; Trianos et al., 2012). Characteristics
related to successful ultrasound-guided cannulation have been found to be larger vein diameter, while depth did not affect success
rate for veins less than 1.6 cm deep and patient characteristics such as age, gender, race, body mass index or medical history did not
impact success rate (Panebianco et al., 2009). The literature provides guidance for several parameters to consider for ultrasoundguided IV access.
Educational Considerations
Using ultrasound for IV access requires training for the user. The type and length of time for this training varies in the literature.
For physicians training is incorporated into residency training with up to sixteen hours of didactic and over 100 ultrasound scans
(Costantino et. al, 2005; Panebianco et. al, 2009). For nursing staff and ED technicians training sessions include at least a 1-hour
didactic with additional hands-on training time (Bauman, Braude, & Crandall, 2007; Blaivas & Lyon, 2006; Chinnock et. al, 2007;
Schoenfeld, Boniface, & Shokoohi, 2010; Stein et. al, 2009; White, Lopez, & Stone, 2010). White et al. (2010) recommended a
3-hour educational program to include didactic, simulation and hands-on practice prior to beginning an ultrasound-guided IV
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CLINICAL PRACTICE GUIDELINE:
Difficult Intravenous Access
access program. Trianos et al. (2012) recommended that training emphasizes the development of proficiency in both cognitive and
psychomotor skills necessary to demonstrate competency in the use of ultrasound guided IV cannulation techniques. Lamperti et al.
(2012) and Heinrichs et al. (2012) further recommended a standardized ultrasound curriculum for vascular access.
Operator Characteristics
Studies have focused on various operators (e.g., physicians, nurses and ED technicians) as well as different techniques. Two
techniques used and studied include the dual-operator method in which one user handles the ultrasound probe while a second user
inserts the IV catheter and the single-user method in which both activities are performed by one user. The dual-operator technique
by emergency physicians resulted in a 97% first attempt success rate compare to 33% for standard technique, with a decrease in time
to insertion of 13 minutes for ultrasound-guided compared to 30 minutes for control (Costantino et al., 2005). Stein et al. conducted
a randomized trial using the single-operator method which did not yield a significant difference between the ultrasound-guided
approach compared to traditional methods for success rate, time to cannulation or patient satisfaction with the procedure (2009).
Operator experience with ultrasound does have an impact on the rate of successful cannulation. Schoenfeld et al. (2010)
demonstrated two independent factors associated with increasing success rate. The number of previous ultrasound-guided IV
attempts was important, as was the operator’s overall IV experience. This reflects the two skills required to successfully cannulate a
vein using ultrasound-guided techniques: using the ultrasound to visually guide the catheter and successful cannulation of the vessel.
Operator Techniques
The single-operator technique performed by nurses resulted in a 97% overall success rate (Walker, 2009). Of interest, the patients
had undergone an average of 6.4 attempts prior to referral to this study, and then required an average of 1.3 attempts to gain access
with the ultrasound (Walker, 2009). The anterior forearm was used for 69% of the sites with basilic veins accounting for 12%
(Walker, 2009). Blaivas and Lyon (2005) studied the effect of ultrasound use on nurses’ perceived difficulty of obtaining IV access. The nurses
participated in a class on ultrasound-guided techniques and then completed a survey. Although not statistically significant, the
success rate was 89% for short axis and 85% for long axis. However, the study did indicate that the nurse’s perception of how difficult
the access would be statistically improved from “very hard” to “very easy” (p=0.0001; Blaivas & Lyon, 2005).
Chinnock, Thornton and Hendey (2007) studied the prediction of success for nurse initiated ultrasound-guided IV access. The
cannulation success rate for one-person technique was 66% and 72% for two-persons. The overall cannulation success rate was 53%
with a 63% success rate for ultrasound-guided technique of which 83% were successful on the first attempt. The basilic vein had a
better cannulation success rate (70%) than the brachial vein (41%) (Chinnock et al., 2007).
Two studies focused on single user technique by ED technicians (Bauman et al., 2009; Schoenfeld et al., 2010). Bauman et al. (2009)
found similar success rates of 80.5% using ultrasound as compared to traditional methods (70.6%). ED technicians gained access
two times faster with ultrasound-guided techniques than physicians or nurses utilizing standard technique (Bauman et al., 2009).
Bauman et al. (2009) also found a reduced number of skin punctures with ultrasound-guided techniques (1.6 vs. 2.6) and significantly
improved patient satisfaction with the procedure increasing from 4.4 to 7.7 (p=0.0001). The Schoenfeld et al. (2010) study resulted in
a 78.5% success rate, noting that user experience significantly correlated (p<0.001) to success rate.
Patients with Known Difficult IV Access
Systematic reviews and meta-analysis studies conducted by Egan et al., 2013, Lui, Alsaawi, and Bjornsson (2014), and Stolz, Stolz,
Howe, Farrell, and Adhikari (2015) found that in patients with difficult IV access the use of ultrasound-guidance for peripheral
venous access improved first time success rates compared to traditional techniques. All three studies also found that the use of
ultrasound-guidance did not have a statistically significant impact on the time to successful cannulation or the number of skin
punctures required to achieve success (Egan et al., 2013; Lui et al., 2014; Stolz et al., 2015). Egan et al. recommended that ultrasoundguidance be used in patients with difficult IV access when traditional IV access techniques have been unsuccessful. Lamperti et al.
(2012) recommended that ultrasound-guided techniques be considered for peripheral venous line cannulation when difficult access
is anticipated.
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CLINICAL PRACTICE GUIDELINE:
Difficult Intravenous Access
Pediatric Population
Ultrasound-guided technique has been found to useful in the pediatric population (Heinrichs et al., 2013). A systematic review and
meta-analysis by Heinrichs et al. found that ultrasound guided peripheral IV cannulation significantly reduces number of attempts
and procedure time in pediatric patients; however, this evidence is limited to three randomized controlled trials. Two pediatric RCTs
included in this meta-analysis were conducted in an emergency setting (Heinrichs et al., 2012). A study by Bair et al. (2009) found
the first attempt success for ultrasound-guided methods to be 35% compared to traditional methods of 29% with a 6% difference
between the groups. Although, the crossover group who had failed traditional method had a 75% first attempt success rate with
ultrasound-guided methods (Bair et al., 2008). Doniger et al. (2009) performed a randomized control study with an overall success
rate of ultrasound-guided technique at 80% compared to traditional technique at 64%, although this difference was not statistically
significant (p=0.208). However, the ultrasound-guided group had statistically significant improvements in overall time to access
(p=0.001), number of attempts (p=0.004) and number of needle redirections (p< 0.0001) compared to the control group (Doniger
et al., 2009).
Ultrasound-Guided Intravenous Access Conclusions
Ultrasound-guided IV access requires training to establish competency and can be safely performed using single-operator or dualoperator method by physicians, nurses and ED technicians. For patients with known or suspected difficult IV access, ultrasoundguided techniques improve success rates in a timely manner with improved patient satisfaction. Based on systematic reviews of
the literature, routine use of ultrasound-guided peripheral venous cannulation is not recommended (Trianos et al., 2012; Liu et al.,
2014); however, ultrasound guidance should be considered in patients with known difficult peripheral venous access, especially when
traditional techniques have failed (Egan et al, 2013; Heinrichs et al., 2012; Lamperti et al, 2012; Liu et al., 2014; Stolz et al., 2015).
INTRAOSSEOUS VASCULAR ACCESS
Intraosseous (IO) vascular access dates back as far as the 1920s when the sternum was described as a potential site for transfusions
(Fowler et al., 2007; Horton & Beamer, 2008; MacKinnon, 2009; Paxton, Knuth, & Klausner, 2009; Weiser, Hoffman, Galbraith
& Shavit, 2012). The IO route was later used by military medical personnel during WWII when vascular access was needed for
patients in shock and IV cannulation was difficult or delayed (Fowler et al., 2007). Subsequently, the availability of plastic catheters
for peripheral and central IV access resulted in a decline in IO usage. IO access has been the standard of care for over 20 years for
the pediatric population when vascular access was difficult to accomplish (Horton & Beamer, 2008). There are three different types
of IO needle placement methods. First, the manual needle is a hollow needle with a removable stylet. The second type is the impact
driven device, of which there are two types; one is designed for sternal access, the other is a spring-loaded injector mechanism
designed for the tibia. The third type is a battery-powered, drill-based technology. The recent introduction of these various IO
insertion devices has made the IO route an option for vascular access in the adult population as well as the pediatric population
(Langley & Moran, 2008; MacKinnon, 2009; Voigt, Waltzman & Lottenberg, 2012; Von Hoff, Kuhn, Burris, & Miller, 2008;
Consortium on Intraosseous Vascular Access in Healthcare Practice, 2010). Leidel et al. (2009) noted there are three lengths of
IO needles available for the drill device to accommodate the pediatric, adult, and obese patients.
The Consortium on Intraosseous Access in Healthcare Practice (2010) was attended by representatives of multiple organizations
with a goal of reviewing the evidence supporting use of the IO access method wherever vascular access was deemed medically
necessary and difficult to achieve. Among the recommendations made by the Consortium is that IO access should be considered as
an alternative to peripheral or central IV access when an increase in patient morbidity or mortality is possible. Further, for patients
not requiring long-term vascular access or hemodynamic monitoring, IO access should be the first alternative to failed peripheral
venous access (Consortium on Intraosseous Vascular Access in Healthcare Practice, 2010). Voigt et al. (2012) conducted a systematic
review of the literature and further added that underutilization of intraosseous access continues despite strong evidence supporting
IO access and recommendations from numerous reputable medical organizations.
Frequently brought into question regarding IO access is which medications can be given via the IO route, and are dosages equivalent
to those given by other routes. The IO route is effective for the administration of blood and blood products, fluid administration, drug
delivery, and blood sampling (Burgert, 2009; Paxton et al., 2009; Leidel et al., 2009). The efficacy of medication route administration
was studied by Von Hoff et al. (2008) in a Latin square crossover study with each subject serving as their own control. Each subject
received a dose of morphine sulfate either through an implanted IO needle or through a peripheral IV line, followed by a second dose
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CLINICAL PRACTICE GUIDELINE:
Difficult Intravenous Access
at least 24 hours later given via the alternate administration route. Serial blood sampling followed each administration to identify
morphine sulfate plasma concentrations. There were no significant differences between the IV and IO routes on plasma morphine
concentration vs. sampling time or pharmacokinetics (Von Hoff, et al., 2008). There was a statistically significant difference in the
volume of distribution in the central compartment thought to be due to the deposition effect near the IO needle.
The literature search revealed three studies which looked at several parameters that demonstrate the usefulness of IO access. These
included success rate of the IO access on first attempt, time to insertion of the IO access, patient report of pain with insertion, and
patient report of pain with fluid administration.
Success Rate on First Attempt
Horton and Beamer (2008) found a 93% first time success rate but did not discuss the specific parameters defining success. Leidel
et al. (2009) attained 90% first time success; success was measured as successful administration of drugs or infusion solutions on
first effort. The success rate of the IO access on first attempt was reported by Paxton et al. (2009) as 80.6% in the proximal humerus.
No determining factors for success were identified in this study. Leidel et al. (2012) conducted a study to evaluate first time success
rate comparing IO access to CVC placement in patients requiring medical or trauma resuscitation and found that the success rate for
IO placement was 85% compared to a CVC line first attempt placement success rate of 60% (X2 = 5.078, df = 1, p = 0.024). Success
was defined as successful administration of fluids or medications via the newly established IO or CVC (Leidel et al., 2012).
Time to Insertion
Horton and Beamer (2008) reported an insertion time of less than 10 seconds in 80.2% of subjects. Measurement began at the time
of needle to skin contact to needle placement in the IO space. Leidel et al. (2009) reported a time of 2.3 + 0.8 minutes insertion
time. Timing was measured by an independent researcher who measured time from picking up the IO access device, preparing the
set, prepping the site, insertion of the IO needle, and administration of the first drug or fluid. Paxton et al. (2009) reported a time
of 1.5 minutes for IO insertion in the proximal humerus. Timing began with the skin preparation before insertion and ended when
the person completing the insertion deemed flow of the fluid was adequate. Leidel et al. (2012) found a significant difference in
time to insertion when comparing IO access with CVC line placement with IO placement being six minutes faster (p < 0.001, 95%
confidence interval [CI] 5.0-7.0 min).
Patient Report of Pain on Insertion
Paxton et al. (2009) assessed pain scores utilizing a visual analogue scale (VAS) on insertion of the IO access device into the
proximal humerus in adult patients with a Glasgow Coma Scale (GCS) score of 15 and reported an average score of 4.5. Horton and
Beamer (2008) reported a mean pain score of 2.3 + 2.8 on IO insertion in pediatric patients with a GCS greater than 8. Leidel et al.
(2009) did not study pain on insertion.
Patient Report of Pain on Infusion
Paxton et al. (2009) assessed pain scores utilizing a VAS on infusion of fluids through the IO port in patients with GCS score of 15
and reported an average score of 3.8 following lidocaine administration. All patients were given a standard dose of 40 to 100 mg of
lidocaine 2% through the IO needle prior to infusion of fluids or medications. Horton and Beamer (2008) reported a mean pain score
of 3.2 + 3.5 on infusion of fluids through the IO port in patients with a GCS greater than 8, without mention of administration of
lidocaine. Leidel et al. (2009) and Leidel et al. (2012) did not study pain on infusion of fluids.
Intraosseous Vascular Access Conclusions
In light of the evidence presented here, IO access provides vascular access in a timely manner when faced with difficult IV access.
This conclusion is supported by the consistent first attempt success rate and rapid time to insertion. IO access is still significantly
underutilized in emergency care and should be considered when rapid vascular access is needed and the patient presents with
difficult peripheral venous access.
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CLINICAL PRACTICE GUIDELINE:
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SUBCUTANEOUS REHYDRATION THERAPY
Also known as hypodermoclysis, subcutaneous rehydration therapy (SCRT) dates back to 1913 (Spandorfer, 2011) as an alternative
for rehydration in mild to moderate dehydration when oral or IV hydration is not feasible. The physiology behind SCRT stems from
the sodium-potassium pump providing an osmotic gradient. The subcutaneous tissue forms a thick matrix with hyaluronic acid
(Allen et al., 2009, Kuensting, 2011; Spandorfer, 2011). A recent innovation in SCRT involves the administration of hyaluronidase
which modifies the permeability of connective tissue, decreasing the viscosity of the cellular cement and promoting absorption of
injected fluids. By injecting hyaluronidase into the subcutaneous tissue, the permeability of the matrix is increased and allows space
for the infusion of fluid. The site selected for infiltration should be an area where skin and the subcutaneous tissue can be pinched.
The preferred site in children is between the scapula (Kuensting, 2011) whereas in adults, the thighs, abdomen and arms can also be
used (Remington & Hultman, 2007). Fluid may be infused by gravity or by pump at a rate of 20 to 125 mL/h over a 24-hour period.
Absorption of fluid is dependent on the osmotic gradient, not on the rate of administration (Kuensting, 2011).
Allen et al. (2009) studied hyaluronidase facilitated SCRT in children ages 2 months to 10 years old (N=51) to analyze rehydration
and possible adverse events. The initial subcutaneous catheter was placed upon first attempt 90.2% (46/51) with successful
rehydration for 84.3% (43/51) patients. There was one case of cellulitis at the site. The nurses who completed the procedure
considered it easy to perform for 96% (46/51) of patients with 90% (43/48) of the parents rating satisfied to very satisfied with the
procedure (Allen et al., 2009). Spandorfer and colleagues (2012) conducted a randomized controlled clinical trial to evaluate whether
rHFSC fluid administration can be safely and effectively administered with volumes similar to IV infusions in mildly to moderately
dehydrated children. &KLOGren age one month to 10 years were randomized to receive 20ml/kg of isotonic fluids using rHFSC
or IV infusion over one hour and then until clinically rehydrated (including the inpatient phase of care for admitted children). The
primary outcome was mean total volume infused, which showed that more fluid was administered intravenously thDn subcutaneously
when including ED and inpatient phases of care (31.2 (24.17) mL/kg via the rHFSC route (n73) delivered over 3.1 hours (mean) versus
35.8 (52.43) mL/kg delivered via IV (n 75) over 6.6 hours (p =0.51). However, when evaluating only the ED volumes infused the
subcutaneous route was shown to be noninferior (28.7 (16.52) mL/kg rHFSC and 22.2 (16.68) mL/kg IV [p= 0.03]). Spandorfer et al.
concluded that subcutaneous hydration facilitated by rHFSC is a reasonable treatment option in the emergency setting for pediatric
patients that are mildly to moderately dehydrated, especially for children with difficult IV access. This finding was supported by a
retrospective descriptive study conducted by Kuensting (2013) that explored whether administration of subcutaneous fluids enhances
the success of venous cannulation. Kuensting compared children that received SCRT prior to IV attempts to children that received
SCRT after failed IV attempts and found that the SCRT group experienced significantly less time to infusion start (21 minutes)
than the IV/SCRT group (97 minutes). The SCRT group also had fewer needle sticks (median = 1) than the IV/SCRT group (median
= 5). Findings provide preliminary evidence that initial SCRT may improve IV access in mildly to moderately ill children in the
emergency setting; however, larger scale RCT research is needed to validate these findings.
Remington and Hultman (2007) reviewed literature on SCRT and identified eight studies. When comparing SCRT with IV
administration from a safety perspective, the two were found to be comparable. It is noted, however, subjects in these studies
were elderly, with a mean age ranging from 71 to 85 years. The incidence of systemic adverse effects did not differ (Remington &
Hultman, 2007). Remington and Hultman showed more subjects improved clinically with IV administration than with SCRT, but the
difference was not statistically significant (81% IV, 57% SCRT, p=0.19). Site changes were necessary on average every 2 days with
SCRT and 2.8 days for IV administration (p=0.14) (Remington & Hultman, 2007; Slesak, Schnurle, Kinzel, Jakob, & Dietz, 2003).
Median duration of fluid administration was six days with both SCRT and IV routes (Slesak et al., 2003). Nurses rated the feasibility
of SCRT equal with IV catheter (Remington & Hultman, 2007; Slesak et al., 2003). Nursing time to initiate SCRT was significantly
lower at 3.4 minutes versus 6.1 minutes for initiation of an IV catheter. A significant difference was seen in the median volume of
solution administered with 750 mL/day for SCRT and 1000 mL/day for IV administration (p=0.002; Slesak et al., 2003).
In summary, SCRT may be an effective intervention for rehydration of mild to moderately dehydrated pediatric and adult patients in
the emergency setting. First line treatment for pediatric patients with mild to moderate dehydration is oral rehydration using an oral
rehydration solution (Wolf & Delao, 2015). Parenteral rehydration, including SCRT, should only be initiated after oral rehydration
has been attempted in mild to moderately dehydrated patients. For further guidance on the treatment of pediatric dehydration, please
see the Emergency Nurses Association, Translation into Practice (TIP) guidance for Pediatric Oral Rehydration.
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CLINICAL PRACTICE GUIDELINE:
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WARMING
The use of heat to facilitate vasodilatation for IV insertion is widely practiced. Caution must be used with this technique as burning
may occur if not closely monitored and controlled. The U.S. Food and Drug Administration (FDA) issued a patient safety warning in
2002 against the practice of using forced air warmers without the blanket in a practice known as “hosing” because second and third
degree burns have resulted (FDA, 2002).
Studies specific to the ED setting are limited. Lenhardt, Seybold, Kimberger, Stoiser, and Sessler (2002) conducted a randomized
control study with a crossover trial of warming using a specific device to facilitate IV cannulation in adult neurosurgery and
hematology patients. The study compared passive warming using a carbon fiber mitt and active warming when powered on and heated
to 52˚C. The initial study found that after 15 minutes of warming the success rate for IV cannulation was 94% (44/50) in the active
warming group compared to 72% (36/50) in the passive warming group (p=0.008). Additionally, the cannulation required less time
with active warming, 36 seconds compared to 62 seconds for passive warming. The crossover trial applied warming for 10 minutes
with a success rate of 95% for the active warming group compared to the 73% passive warming group (p=0.001). The time required
for successful cannulation was 20 seconds shorter with active compared to passive warming (p=0.02; Lenhardt et al., 2002).
Fink, Hjort, Wenger, Cook, and Cunningham (2009) conducted a randomized controlled study to compare dry heat with moist heat.
Dry heat was 2.7 times more likely to result in successful IV insertion on first attempt (p=0.039). The difference in mean insertion
time between dry heat (98.5 seconds) and moist heat (127.6 seconds) was large enough to be clinically meaningful. No significant
difference in patient anxiety was found between the heat modalities or between nurses or post-insertion patient reported anxiety
scores (p > 0.54). The conclusion recommended dry heat due to low cost, safety to patients and feasibility (Fink et al., 2009)
The use of EMLA Cream™ to decrease pain for pediatric patients is common practice which may result in vasoconstriction of
the vein. 1Huff, Hamlin, Wolski, McClure, and Eliades (2009) evaluated the effect of heat with EMLA Cream™ to facilitate
IV cannulation. The vein size was measured using ultrasound technology prior to EMLA Cream™ application, one hour after
application of EMLA Cream™, and 2 minutes after heat applied. The vein measurements over time were statistically significant
(F=2.58, p=.000), indicating approximately 51% variance in vein measurement which was attributed to EMLA Cream™ and or heat
when other conditions are stable. The average vein measurement at baseline was 0.243 cm, after EMLA Cream™ 0.205 cm and with
heat 0.253 cm. The difference in vein visualization was also statistically significant (F=2.58, p=.000). The study had an 80% first
cannulation success rate (Huff et al., 2009).
In summary, controlled warming to facilitate IV cannulation is a low-cost adjunct to improve cannulation success rate in
a timely manner
ALTERNATIVE METHODS
Noting the frustration experienced by healthcare professionals when faced with establishing IV access in the ED, several groups
have devoted time to identifying tools to assist with IV access. Near infrared light illuminates the skin without ionizing radiation
and produces a 2-D image of blood filled structures (Perry, Caviness & Hsu, 2011). The literature reviewed in this section was
limited to pediatric populations. Perry et al. (2011) found the nursing staff (N=14) felt the device was beneficial for 90% for those
patients who had difficult IV access. Further, 70% of the nurses surveyed found the device helpful for dehydrated patients and 80%
in the chronically ill population. However, there was no significant difference in the first attempt success rate between standard IV
techniques (N=62, 79%) and the infrared device (N=61, 72.1%; Perry et al., 2011). A study by Chapman, Sullivan, Pacheco, Draleau,
and Becker (2011) evaluated the use of near infrared technology with a population of pediatric emergency patients age 0 to 17 years.
Participants were randomized to the standard peripheral IV only group or the IV with VeinViewer assisted group. According to
Chapman et al. there was no statistically significant difference in time to IV placement or first time success rates (78% in standard
technique group and 79% in the VV group; x2(1)=0.39, p = 0.53) between the two groups. Szmuk et al. (2013) also conducted a
study comparing traditional IV access techniques to IV with VeinViewer assistance in pediatric patients age 0-18 years. This study
was ended early based on the harm threshold being crossed for the primary outcome measure [first attempt insertion success]
(Szmuk et al., 2013). Preliminary findings indicated that use of the near infrared device worsened first time success rates when used
by experienced pediatric nurses (Szmuk et al., 2013).
The following databases were searched: PubMed, Google Schola
1
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Transillumination of veins using fiber optics in pediatric patients iV another method studied (Katsogridakis et al., 2008).
Transillumination did not improve first attempt success (p=0.53), rather, use of a safety catheter (p=0.01), vein visibility (p=0.01)
and palpability (p=0.02) were better predictors of first attempt success (Katsogridakis et al., 2008).
A Vein Entry Indicator Device (VEID™) is a small box with a pressure sensor that fits onto an IV cannula. When a change in
pressure in the needle indicates penetration of the vessel, a continuous beep sounds and reduces the likelihood of exiting the back
wall of the vein. The VEID™ was studied by Simhi, Kachko, Bruckheimer, and Katz (2008) and found to help reduce the number
of attempts at IV cannulation. The VEID™ is not currently available in the United States.
In summary, these alternative methods may be useful adjuncts for patients with difficult IV access; however, the evidence is mixed
and indicates that they may have no clinical benefit when used by experienced pediatric emergency nurses. Based on the mixed
nature of the available research findings and the limited number of high quality studies there is insufficient evidence to recommend
these alternative methods to facilitate peripheral IV access.
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Description of Decision Options/Interventions and the Level of Recommendation
Conclusions and recommendations about alternatives to venous access in the patient with difficult IV access in the ED:
1. Ultrasound-Guided Intravenous Access
◦◦ Ultrasound-guided access should be considered for adult and pediatric patients with difficult access that have had
unsuccessful PIV attempts using traditional methods. Level A - High. (Egan et al., 2013; Heinrichs et al., 2013; Liu et al.,
2014; Stolz et al., 2015)
◦◦ Ultrasound-guided IV access is a technique that can effectively be performed by physicians, nurses and ED technicians.
Level A - High. (Costantino, et al., 2005; Panebianco, et al., 2009; Bauman, Braude & Crandall, 2007; Blavis & Lyon, 2006;
Chinnock et al., 2007; Schoenfeld, Boniface & Shokoohi, 2010; Stein et al., 2009)
◦◦ Ultrasound-guided techniques may result in improved patient satisfaction. Level C - Weak. (Bauman et al., 2009)
◦◦ When the external jugular access is not visible, ultrasound-guided peripheral access is significantly more successful than
external jugular access. Level C - Weak. (Costantino et al., 2005)
2. Intraosseous Vascular Access
◦◦ Intraosseous venous access is significantly more expeditious than standard IV access and should be considered early when
known or suspected difficult IV access exists. Level A - High. (Leidel et al., 2009; Leidel et al., 2012)
◦◦ In alert patients, pain with intraosseous access insertions is rated as minor. Level A - High. (Paxton et al., 2009)
◦◦ Lidocaine administration prior to medication infusion reduces the pain felt by alert patients. Level C - Weak. (Paxton
et al., 2009)
3. Subcutaneous Rehydration Therapy
◦◦ SCRT is an alternative to peripheral IV insertion for the mildly to moderately dehydrated pediatric and elderly patients when
oral rehydration efforts have been unsuccessful. Level B - Moderate. (Allen, et al., 2009; Remington & Hultman, 2007;
Slesak, et al., 2003)
4. Warming
◦◦ Application of heat improves IV success rate and decreases time required to gain access. Level B - Moderate. (Lenhardt, et al., 2002)
– Dry heat may be more effective than moist heat. Level C - Weak (Fink, et al., 2009)
◦◦ For pediatric patients, heat may counteract the vasoconstriction associated with EMLA Cream™. Level C - Weak.
(Huff, et al., 2009)
5. Alternative Methods
◦◦ There is inadequate evidence to support the use of infrared light, transillumination, and the VEID™ devices. Level I/E.
(Chapman et al, 2011; Katsogridakis et al., 2008; Perry, Caviness & Hsu, 2011; Simhi et al., 2008; Szmuk et al., 2013).
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Authors
2015 ENA Clinical Practice Guideline Committee:
Anna Maria Valdez, PhD, MSN, RN, CEN, CFRN, CNE, FAEN
Alysa Reynolds, RN
Mary Alice Vanhoy, MSN, RN, CEN, CPEN, NREMT-P, FAEN
Marylou Killian, DNP, MS, RN, CEN, FNP-BC, FAEN, Chairperson
Marsha Cooper, MSN, RN, CEN
Karen Gates, DNP, RN, NE-BC
Mary Kamienski, PhD, APRN, CEN, FAEN, FAAN
David McDonald, MSN, RN, APRN, CEN, CCNS
Janis Farnholtz Provinse, MS, RN, CNS, CEN
Nancy Erin Reeve, MSN, RN, CEN
Anne Renaker, DNP, RN, CNS, CPEN
Stephen Stapleton, PhD, MSN, MS, RN, CEN, FAEN
Patricia Sturt, MSN, MBA, RN, CEN, CPEN
Mary Ellen Zaleski, MSN, RN, CEN
ENA 2015 Board of Directors Liaison:
Jean A. Proehl, MN, RN, CEN, CPEN, FAEN
ENA Staff Liaisons:
Lisa Wolf, PhD, RN, CEN, FAEN
Altair Delao, MPH
Acknowledgments
ENA would like to acknowledge the following member of the 2015 Institute for Emergency Nursing Research (IENR) Advisory
Council for her review of this document:
Martha McDonald, PhD, RN, CEN, CCNS, CCRN, CNE
Developed: December 2011
Revised: October 2015
© Emergency Nurses Association, 2015.
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915 Lee Street, Des Plaines, IL 60016-6569 ¡ 800.900.9659 ¡ www.ena.org ¡ Follow us
16
CLINICAL PRACTICE GUIDELINE:
Difficult Intravenous Access
Appendix 1: Evidence Table
Reference
Findings/Implications
Quality of
Evidence
(4-point scale)*
Level of
Evidence
(7-point scale)**
Findings: The study did not find significant
difference, the traditional technique
had 70.6% success rate compared to US
guided technique with an 80.5% success.
Post hoc analysis using 3 attempts as
failure resulted in a significant improved
success rate CI 14.5%, US rate 80.5%
and traditional 44.1%. US was 2 times
faster than control. US (26.8 minutes)
was significantly less time to gain access
compared to control (74.8 minutes).
Traditional technique required more skin
punctures (mean 3.6) compared to US
(mean 1.6). US-guided had higher patient
satisfaction (70) compared to traditional
methods (44). Conclusion: The use of
US guidance after brief training for PIV
access, EDT had same rate of success
as traditional methods; significantly
improved speed of access and reduced
number of skin punctures.
I
IV
Design- prospective observational
Measures: Perceived
study. IRB approved. Method: Nurses
No statistically significant difference
difficulty with US
introduced to US-guided PIV access in
in BCC between CHX (3.13%) & TI.
class prior to study. Lab practice prior to
techniques and the #of
(2.72%)- difference 0.41% (p= 0.188).
Measure the effect of US
blind attempts. Nurses
study with blue phantom simulation, then
CHX has lower cost ($0.16 less per kit),
on perceived difficulty by
rated attempts using US
attempted PIV using Sonosite US machine
faster drying time (40 sec less), and is
emergency nurses to gain PIV
from "very hard" to "very
and asked to completed questionnaire.
access in ED patients
associated with less mess. BCC
N=321. Surveys completed by 23 RNs
easy." Short axis and long
was lowest when dedicated staff
axis vein visualization were
in a 5 month period.
collected BC.
also measured.
Setting: Level 1 trauma center with 75,000
annual census.
I
III
Research/Purpose
Questions/Hypothesis
Design/Sample
Setting
Variables/Measures
Analysis
Ultrasound-guided Intravenous Access
Bauman, M., Braude, D.,
& Crandall, C. (2009).
Ultraound-guidance
vs. standard technique
in difficult vascular
access patients by ED
technicians.
Am J Emerg Med,
27(2):135-40.
doi: 10.1016/j.
ajem/2008.02.005
Blaivas, M. & Lyon, M.
(2006). The effect of
ultrasound guidance on
the perceived difficulty
of emergency nurseobtained peripheral
IV access. J Emerg
Med, 31(4):40710. doi: 10.1016/j.
jemermed.2006.04.014
Evaluate the efficacy
(success, time, # of
punctures) and safety and
patient satisfaction of USguided PIV access by ED
technicians in patients with
DIA access compared to
traditional methods.
Design: Two phase prospective systematically
allocated non-blinded cohort study. Expedited
IRB review and approval. Method: Single
user technique using Sonosite Micromax
or Titan model US machines.
Sample: Convenience Adult ED patients
(N=75) with difficult IV access as defined
by 2 missed attempts. Phase 1 (n=34).
PIV was via traditional methods. EDT
had training on US-guided technique.
Phase 2 (n=41) data collected on usguided methods after training.
Setting: 350 bed urban, university
teaching hospital /trauma center.
Measures: Primary and
secondary outcomes
measured include success
rate, # of punctures, time
on task, satisfaction, use of
additional personnel and
complications. Statistical
Analysis: Difference in
phases analyzed using
Newcombe-Wilson Hybrid.
Unpaired t-tests were also
used. Satisfaction was
analyzed via Wilcoxon
Rank Sum test.
17
CLINICAL PRACTICE GUIDELINE:
Difficult Intravenous Access
Appendix 1: Evidence Table
Reference
Chinnock, B., Thornton,
S., & Hendey, G.W.
(2007). Predictors
of success in nurseperformed ultrasoundguided cannulation. J
Emerg Med, 33(4):401405. doi:10.1016/j.
jemermed.2007.02.027
Costantino, T. G.,
Parikh, A. K., Satz,
W. A., & Fijtik, J. P.
(2005). Ultasonographyguided peripheral
intravenous access versus
traditional approaches
in patients with difficult
intravenous access.
Ann Emerg Med, 46(5):
456-61. doi:10.1016/j.
annemergmed.2004.
12.026jannemergmed.
2004.12.026
Research/Purpose
Questions/Hypothesis
Study Purpose: To determine
how the choice of vein, the
reason for difficult access,
or the one- vs two-person
technique affected the success
rate of nurse-performed
US-guided IV cannulation in
patients with difficult
IV access.
Compare US-IV with
traditional PIV access in
difficult to obtain IV by
experienced ED RN (defined
as 3 missed attempts).
Design/Sample
Setting
Prospective, observational study.
US-guided cannulation was attempted
after two failed peripheral attempts and
no other visible potential sites
for cannulation.
Sample: 100 subjects of a largely
low-income population. 18 nurses
enrolled patients.
Setting: Urban, academic center with
an annual ED volume of 60,000 visits.
Convenience sample. IRB approved.
Attempt N=119; Patient success N=100.
Design: prospective, non-blinded,
systematically allocated comparison
study. IRB approved. Method: ED
residents performed 2 user technique
using either Seimens Versapro or
Sonosite machines for US guided
technique. EJ was included in traditional
technique methods.
Sample: convenience sample n=60
randomized according to odd (n-39) or
even (n-21) day. Pediatric and pregnant
patients were excluded. Inclusion
criterion was inability to gain access
in 3 attempts or based on prior history,
obesity, IV drug use or chronic medical
conditions. Setting: urban tertiary
university ED.
Variables/Measures
Analysis
Findings/Implications
Quality of
Evidence
(4-point scale)*
Level of
Evidence
(7-point scale)**
Documentation of the
perceived difficulty of
venous access; were the
veins sonographically
visible; had the patient
needed previous central
venous access (added late
in the study). 90-minute
training session of lecture,
hands-on use of the UC,
short axis approach, 1
and 2 person technique.
Documentation of a flash
of blood and cannulation
success (defined as
remained in place until
completion of therapy).
Cannulation success rate was 63%, of
which 83% were successful on the first
attempt; overall success rate was 53%.
The basilic vein had a better cannulation
success rate (70%) than the brachial vein
(41%). Successful cannulation occurred
in users of IV drugs 62% of the time;
success for obese patients was 62% and
for patients with multiple prior medical
problems, 64%. Cannulation success rate
for one-person technique was 66% and
72% for two-person technique.
II
VI
Findings: US guided PIV is more
successful (97%) than traditional
methods (33%), require less time (13
minute vs 30), decreased number of
punctures (1.7 vs 3.7), and improved
patient satisfaction (8.7 vs 5.7).
II
VI
Measures: IV success rate,
time to first successful
cannulation, time for
request to cannulation,
number of attempts,
patient satisfaction, and
complications.
Statistical Analysis:
Descriptive, SD, MannWhitney U analysis of
variance.
18
CLINICAL PRACTICE GUIDELINE:
Difficult Intravenous Access
Appendix 1: Evidence Table
Reference
Costantino, T.G., Dirtz,
J.F., & Satz, W.A.
(2010). Ultrasoundguided peripheral
venous access vs. the
external jugular vein
as the initial approach
to the patient with
difficult vascular access.
Journal of Emergency
Medicine, Oct. 39(4):
462-467. doi: 10.1016/j.
jemermed.2009.02.004
Egan, G., Healy, D.,
O’Neill, H., ClarkeMoloney, M., Grace, P.
A., & Walsh, S. R. (2013).
Ultrasound guidance
for difficult peripheral
venous access: systematic
review and metaanalysis. Emerg Med J,
30(7):521-6. doi: 10.1136/
emermed-2012-201652
Research/Purpose
Questions/Hypothesis
Design/Sample
Setting
Variables/Measures
Analysis
Findings/Implications
Quality of
Evidence
(4-point scale)*
Level of
Evidence
(7-point scale)**
Study Objective: To determine
which initial approach by
emergency physicians,
ultrasound-guided peripheral
IV access vs external jugular
vein cannulation, is more
readily successful, in patients
with difficult IV access.
Prospective, randomized controlled
trial. Performed by 2nd and 3rd year
emergency medicine residents who had
completed at least 5 successful external
jugular (EJ) insertions and 5 US-guided
peripheral IV cannulations. Completed
emergency US rotation with 16 hours
didactic and at least 150 US scans.
Cross-over pathway utilized if the subject
failed the first arm randomized to.
Sample: All ED patients who failed at
least 3 nursing attempts at peripheral IV
access. Minimum age 18 years. Patients
needing a central line were excluded.
N=32 in the US-guided arm; N=28 in the
EJ arm. Setting: Urban, tertiary-care
university hospital ED (60,000 annual
ED visits).
Primary endpoint was
successful cannulation
defined as aspiration of 5
mL of blood and infusion
of IV solution. Secondary
endpoints were the number
of successfully cannulated
IV lines by each technique,
time to cannulation,
functioning lines at
the conclusion of ED
treatment, and observed
complications. Success
rate comparisons were
measured with Fisher’s
exact methods. Time data
and age were compared
with Mann-Whitney U or
Student’s t-test methods.
Success rate for the US-guided arm
was 84% vs 50% for the EJ arm, which
is statistically significant. Overall
success after cross-over data was
considered was 89% for USIV and 55%
for EJ. Time to cannulation for USIV
was 8.9 mins. vs 8.1 mins. for EJ.
89% of US-IVs were functioning at
the conclusion of ED treatment vs 93%
of EJ lines. No complications were
observed in either group. Conclusion:
US-IV statistically superior over EJ
IV cannulation.
I
II
Design: Meta analysis and systematic
review of MEDLINE and
EMBASE database.
Sample: identified 15,405 citations,
assessed 62 abstracts for eligibility,
and included 7 RCTs in meta-analysis
for a total of 289 patients.
All age groups included.
Primary outcome was
successful PIV insertion.
Secondary outcomes were
time to successful PIV
cannulation and number
of skin punctures. Study
conducted in accordance
with the Preferred
Reporting Items for
Systematic Reviews and
Meta-Analysis (PRISMA)
guidelines. Study quality
was measured using Jadad
score. Statistics: Random
effects models; Cochran Q
test, Egger test.
Findings: Ultrasound guidance
increases the likelihood of successful
cannulation in difficult access patients.
However, USGIV had no significant
effect on time to cannulation or
number of punctures.
I
I
Systematic review and
meta-analysis to evaluate the
effectiveness of ultrasound
guided peripheral IV
cannulation in comparison
to standard technique in
patients known to have
difficult access.
19
CLINICAL PRACTICE GUIDELINE:
Difficult Intravenous Access
Appendix 1: Evidence Table
Reference
Heinrichs, J., Fritze, Z.,
Vandermeer, B., Klassen,
T., & Curtis, S. (2013).
Ultrasonographically guided
peripheral intravenous
cannulation of children and
adults: a systematic review
and meta-analysis. Ann
Emerg Med, 61(4):44454.e1. doi:10.1016/j.
annemergmed.2012.11.014
Lamperti, M., Bodenham,
A. R., Pittiruti, M.,
Blaivas, M., Augoustides,
J. G., Elbarbary, M., ...
Verghese, S. T. (2012).
International evidencebased recommendations
on ultrasound-guided
vascular access. Intensive
Care Med, 38(7):1105-17.
Liu, Y. T., Alsaawi, A.,
& Bjornsson, H. M.
(2014). Ultrasound-guided
peripheral venous access:
A systematic review of
randomized-controlled
trials. Eur J Emerg Med,
21(1):18-23. doi:10.1097/
MEJ.0b013e328363bebc
Research/Purpose
Questions/Hypothesis
Design/Sample
Setting
Variables/Measures
Analysis
Findings/Implications
Quality of
Evidence
(4-point scale)*
Level of
Evidence
(7-point scale)**
Systematic review and
meta-analysis to evaluate
US guidance as an aid to
PIV insertion.
Design: Meta analysis and systematic
review of MEDLINE, Cochrane
Central Register of Controlled Trials,
EMBASE, Cumulative Index to
Nursing and Allied Health Literature
(CINAHL), Web of Science,
ClinicalTrials.gov, and Google.ca.
Sample: identified 4,664 citations,
assessed 403 full texts for eligibility,
and included 9 trials. Five had low risk,
1 high risk, and 3 unclear risk of bias.
Setting: ED and OR setting
Primary outcomes
included PIC success rates,
# of attempts, time for
procedure and time from
randomization to PIV
success. Instruments: The
Preferred Reporting Items
for Systematic Reviews and
Meta-Analysis; Cochrane
Risk of Bias Tool. Statistics:
IQR, RRR, I2 statistic
Findings: USG IV may reduce PIV
attempts and procedure time in
pediatric ED and OR patients. Few
studies outcomes reached statistical
significance. Larger well controlled
studies needed for evidence based
recommendations.
I
I
Provide expert consensus
on evidence related to USG
vascular access
Design: Systematic review
of the literature
Sample: A total of 229 articles were
collated into a single bibliography.
All of these articles were individually
appraised on the basis of
methodological criteria to determine
the initial quality level..
Not applicable
Findings: Nine definitions and 50
evidence based recommendations
related to technology, use of US
guidance in children and adults, and
procedural considerations
were developed.
I
I
Systematic review to evaluate
the effect of using ultrasound
guided peripheral IV
cannulation in patients with
difficult IV access.
Design: Systematic review of Medline,
SCOPUS, Google Scholar, Cochrane
Central Register Archive, WHO
International Clinical Trials Registry,
CINAHL, and society conference
proceedings.
Sample: identified 1,778 titles identified,
50 studies had full text comprehensive
review, and included 6 RCTs in metaanalysis for a total of 316 patients (153
in control group and 163 I US guided
group). All ages included.
Primary outcome was
success rate of PIV
cannulation. Secondary
outcomes were time to
successful PIV cannulation
and number of attempts.
Study conducted in
accordance with the
Preferred Reporting Items
for Systematic Reviews and
Meta-Analysis (PRISMA)
guidelines.
Primary outcome was success rate of
PIV cannulation. Secondary outcomes
were time to successful PIV cannulation
and number of attempts.
Study conducted in accordance with
the Preferred Reporting Items for
Systematic Reviews and Meta-Analysis
(PRISMA) guidelines.
I
I
20
CLINICAL PRACTICE GUIDELINE:
Difficult Intravenous Access
Appendix 1: Evidence Table
Reference
Research/Purpose
Questions/Hypothesis
Design/Sample
Setting
Variables/Measures
Analysis
Findings/Implications
Quality of
Evidence
(4-point scale)*
Level of
Evidence
(7-point scale)**
Stolz, L. A., Stolz, U.,
Howe, C., Farrell, I. J.,
& Adhikari, S. (2015).
Ultrasound-guided
peripheral venous
access: a meta-analysis
and systematic review.
J Vascular Access,
16(4):321-6. doi: 10.5301/
jva.5000346
Systematic review and
meta-analysis to evaluate to
determine whether success
rates, time to cannulation,
and number of punctures
required for peripheral
venous access are improved
with US guidance compared
with traditional techniques
in patients with difficult
peripheral venous access.
Design: Meta analysis and systematic
review of MEDLINE, Web of Science,
The Cochrane Library, ClinicalTrials.
gov, EMBASE, Cumulative Index to
Nursing and Allied Health Literature
(CINAHL) and Allied Health Literature.
Sample: identified 4,638 articles with
960 duplicates. 3,634 articles excluded.
Assessed 64 full text articles for
inclusion, and included 6 RCTs and 1
prospective study. All ages included.
Primary outcome was PIV
success rate. Secondary
outcomes included time to
successful cannulation and
number of attempts.
Used random effects
models, estimates of
heterogeneity from the
Mantzel-Haenszel Model to
estimate pooled odds ratio
for success, weighted mean
difference for number of
punctures, and time
to cannulation.
Findings: Ultrasound guidance
increases the likelihood of successful
cannulation in difficult access patients.
However, USGIV had no significant
effect on time to cannulation or number
of punctures.
I
I
Troianos, C. A., Hartman,
G. S., Glas, K. E., Skubas,
N. J., Eberhardt, R. T.,
Walker, J. D., & Reeves,
S. T. (2012). Guidelines
for performing ultrasound
guided vascular cannulation: recommendations
of the American Society
of Echocardiography and
the Society of Cardiovascular Anesthesiologists.
Anesth Analg, 114(1):4672.doi:10.1213/ANE.
0b013e3182407cd8
Not applicable
Not applicable
Not applicable
This systematic review provides
numerous evidence based
recommendations for the use
of USGIV.
I
VII
21
CLINICAL PRACTICE GUIDELINE:
Difficult Intravenous Access
Appendix 1: Evidence Table
Reference
Research/Purpose
Questions/Hypothesis
Design/Sample
Setting
Findings/Implications
Quality of
Evidence
(4-point scale)*
Level of
Evidence
(7-point scale)**
Not applicable
Review of the clinical background,
considerations, types of IO devices,
contraindications to IO, complications,
and other considerations. Recommendations: Among the recommendations is
that IO should be considered as an alternative to peripheral or central IV access
when an increase in patient morbidity or
mortality is possible.
I
VII
Mann-Whitney Rank Sum
test applied to analyze the
differences in procedure
times. Significance level of
p = 0.05.
Success rate on first attempt was 90%
for IO vs 60% for CVC. Mean time
for IO cannulation was significantly
shorter for IO (2.3 + 0.8 min.) vs CVC
(9.9 + 3.7 min). One IO failure related
to not reaching the bone marrow due
to incorrect insertion site. Four CVC
failures where the guidewire would not
advance into the vessel. Conclusion:
IO was significantly more successful
and required significantly less time
compared to CVC.
I
VI
Variables/Measures
Analysis
Intraosseous Vascular Access
Consortium on Intraosseous Vascular Access
in Healthcare Practice:
Phillips, L., Brown, L.,
Campbell, T., Miller, J.,
Proehl, J., & Youngberg,
B. (2010). Recommendations for the use of intraosseous vascular access for
emergent and nonemergent
situations in various
healthcare settings: A
consensus paper. J Emerg
Nurs, 36(6):551-6. doi:
10.1016/j.jen.2010.09.001
Leidel, B. A., Kirchhoff,
C., Bogner, V., Stegmaier,
J., Mutschler, W., Kanz,
KG., & Braunstein, V.
(2009). Is the intraosseous
route fast and efficacious
compared to conventional
central venous catheterization in adult patients
under resuscitation in the
emergency department?
A prospective observational pilot study. Patient
Saf Surg, 3(1):24-31. doi:
10.1186/1754-9493-3-24
Not applicable
Not applicable
The aim of this study is to
compare the intraosseous (IO)
access vs central venous
catheter (CVC) access success
rate on first attempt and
procedure time.
Prospective observational study. Ethics
approved. PIV attempted three times
for a maximum of 2 minutes; then,
simultaneous IO and CVC access by two
participants. A third observer timed each
procedure. Procedure time defined as
duration of picking up set for IO/CVC
access thru successful administration
of drugs or infusion.
Sample: Convenience sample of consecutive critically injured or ill patients
18 years of age and over who needed
immediate vascular access. N=10.
Setting: Urban level I trauma center.
22
CLINICAL PRACTICE GUIDELINE:
Difficult Intravenous Access
Appendix 1: Evidence Table
Reference
Leidel, B. A., Kirchhoff,
C., Bogner, V., Braunstein, V., Biberthaler, P.,
& Kanz, K. G. (2012).
Comparison of intraosseous versus central venous
vascular access in adults
under resuscitation in the
emergency department
with inaccessible peripheral veins.
Resuscitation, 83(1):40-5.
doi:10.1016/j.resuscitation.2011.08.017
Paxton J. H., Knuth T.
E., & Klausner H. A.
(2009). Proximal humerus
intraosseous infusion:
a preferred emergency
venous access.
J Trauma, 67(3):60611. doi: 10.1097/
TA.0b013e3181b16f42
Research/Purpose
Questions/Hypothesis
Design/Sample
Setting
Purpose - Compare time to
establish IO versus CVC in
adult resuscitation patients.
Design: Prospective observational
study. IRB approved.
Methods: investigated success rates on
first attempt and procedure times of IO
access versus central venous catheterization (CVC) in adults (≥18 years of age)
with inaccessible peripheral veins under
trauma or medical resuscitation in a level
I trauma centre emergency department.
Sample: Convenience sample of consecutive adult patients under resuscitation
that had inaccessible peripheral
veins N=40. Setting: Urban level I
academic trauma center.
Hypothesis: That proximal
humerus intraosseous (PHIO)
would be faster and easier
than conventional venous
access for the emergent resuscitation of critically ill
or injured patients.
Prospective cohort study. IRB approved.
All study participants underwent educational training in-services and standardized testing on IO catheter placement,
management and removal.
Sample: N=62; Phase 1 included 57 PIV
and 5 CVC; Phase 2 included 29
PHIO catheterizations.
Setting: Urban Level I trauma Center
with an annual ED census of 92,000.
Variables/Measures
Analysis
Findings/Implications
Quality of
Evidence
(4-point scale)*
Level of
Evidence
(7-point scale)**
Primary outcomes were
success rate and procedure time. Statistics: Chi
square, z test, 2-sided Mann
Whitney rank sum test;
Appropriately powered
Findings: IO placement was faster and
failure rates were significantly
lower in IO sites.
Conclusion: IO vascular access is a
reliable bridging method to gain vascular
access for in-hospital adult patients under
resuscitation with difficult peripheral
veins. Moreover, IO access is more
efficacious with a higher success rate on
first attempt and a lower procedure time
compared to landmark-based CVC.
I
VI
Patients who required
venous access and arrived
without adequate venous
access were included.
Phase 1 consisted of data
reflecting time to first
catheter placement (PIV
or CVC), perceived pain,
complications, resuscitation
medications given. Phase
2 consisted of patients who
required a new vascular
access during resuscitation
and underwent PHIO. All
patients in Phase 2 received
a standard dose of lidocaine
before IV infusion.
First attempt success rate 73.7% (PIV);
20% (CVC); 80.6% (PHIO). Mean time
to flow in minutes: 3.6 (PIV); 15.6
(CVC); 1.5 (PHIO). Mean pain score
for insertion: 0.9 (PIV); Unable (CVC);
4.5 (PHIO). Mean pain score infusion
0 (PIV); Unable (CVC); 3.8 (PHIO).
Mean time to good flow is significant
faster for PHIO. No major complications
noted. Results demonstrate that PHIO
placement is quick and easy alternative
for venous access.
I
III
23
CLINICAL PRACTICE GUIDELINE:
Difficult Intravenous Access
Appendix 1: Evidence Table
Reference
Voigt, J., Waltzman, M.,
& Lottenberg, L. (2012).
Intraosseous vascular
access for in-hospital
emergency use: a systematic clinical review of the
literature and analysis.
Pediatr Emerg Care,
28(2):185-99. doi:10.1097/
PEC.0b013e3182449edc
Research/Purpose
Questions/Hypothesis
Objectives: (1) review the
evidence supporting the use
of IO access; (2) determine
the utilization of IO access
as described in the literature;
and (3) assess the level of
specialty society support.
Methods: Electronic and hand
searches were undertaken
to identify relevant articles.
English-language-only
articles were identified.
The Cochrane Review
methodology along with data
forms were used to collect
and review data. The evidence
evaluation process of the
international consensus on
emergency cardiovascular
care was used to assess
the evidence. Studies were
combined where metaanalyses could
be performed.
Design/Sample
Setting
Design: systematic review
Variables/Measures
Analysis
Primary outcomes
measures: Successful
access - percentage of time
successful on first try or
on subsequent tries until
vascular access
was obtained. Time to
access - insertion time.
Secondary measures:
Complications - including
technical, infection (adverse
events), pharmokinetics
and cost.
24
Findings/Implications
Quality of
Evidence
(4-point scale)*
Level of
Evidence
(7-point scale)**
Findings: In levels 2 to 5 studies,
IO access performed better versus
alternative access methods on the end
points of time to access and successful
access. Complications appeared to be
comparable to other venous access
methods. Randomized controlled trials
are lacking. Newer IO access technologies appear to do a better job of gaining
successful access more quickly. Intraosseous access is underutilized in the ED
because of lack of awareness, lack of
guidelines/indications, proper training,
and a lack of proper equipment.
Conclusions: Underutilization exists
despite recommendations for IO access
use from a number of important medical
associations peripherally involved in
the ED such as the American Academy of Pediatrics. To encourage the IO
approach, IO product champions (as
both supporter and user) in the ED are
needed for prioritizing and assigning IO
access use when warranted. In addition,
specialty societies directly involved in
emergent hospital care should develop
clinical guidelines for IO use.
I
I
CLINICAL PRACTICE GUIDELINE:
Difficult Intravenous Access
Appendix 1: Evidence Table
Reference
Research/Purpose
Questions/Hypothesis
Design/Sample
Setting
Weiser, G., Hoffmann, Y.,
Galbraith, R., & Shavit, I.
(2012). Current advances
in intraosseous infusion-a
systematic review. Resuscitation, 83(1):20-6. doi:
http://dx.doi.org/10.1016/j.
resuscitation.2011.07.020
Objectives: To describe the
advancement of Intraosseous
(IO) infusion in the spectrum
of resuscitative protocols and
to provide a systematic review
on currently used semi-automatic IO infusion devices.
Question: “In patients undergoing resuscitation, does
the use of semi-automatic IO
infusion devices compared to
manual needles influence IO
placement success rate, time
for IO placement, and ease-ofuse and user preference?”
Design: systematic review. Methods: The
electronic databases PubMed and Embase
were searched for articles published from
1997 to 2010 using the search terms (“intraosseous”) AND (“needle” or “device”
or “technique”) AND (“infusion” or “injection” or “access”). Google Scholar was
searched to identify articles published in
electronic journals, books, and scientific
websites. Articles were included only
if they compared at least two types of
semi-automatic devices, or compared one
or more semi-automatic device with one
or more manual needles. Reviews, editorials, surveys, and case reports
were excluded.
Variables/Measures
Analysis
Findings/Implications
Primary outcomes
measures: Successful
access - percentage of time
successful on first try or
on subsequent tries until
vascular access
was obtained. Time to
access - insertion time.
Secondary measures:
Complications - including
technical, infection (adverse
events), pharmokinetics
and cost.
Findings: 179 studies identified; 10 met
inclusion criteria. Most studies have
low level of evidence; a few studies
superiority of battery-powered IO
driver over SA IO devices.
Conclusions: Only a few studies
compared the performance of different
types of IO infusion devices, most
of them have a low level of evidence.
These studies suggested a superiority
of the battery-powered IO driver over
manual needles, and other semiautomatic IO infusion devices.
25
Quality of
Evidence
(4-point scale)*
Level of
Evidence
(7-point scale)**
I
I
CLINICAL PRACTICE GUIDELINE:
Difficult Intravenous Access
Appendix 1: Evidence Table
Reference
Research/Purpose
Questions/Hypothesis
Design/Sample
Setting
Variables/Measures
Analysis
Findings/Implications
Quality of
Evidence
(4-point scale)*
Level of
Evidence
(7-point scale)**
Efficacy: 94.1% (48/51) patients received
hydration through SCRT. 84.3% (43/51)
were treated within the ED stay, 9.8%
(5/51) required hospitalization for rehydration. 5.9% (3/51) required alternative
modalities to achieve rehydration. Ease
of use: median time to SCRT infusion
was 2 mins (0-15min). Fluid infusion
began 5 min. after catheter placement in
88% (45/51) of patients. SC access was
gained on first attempt 90.2% (46/51)
and second attempt 9.8% (5/51). Ten
children had failed IV attempts prior to
enrollment in the study. Investigators
rated the procedure as easy for 96%
(49/51) cases. Further the investigators
rated SCRT as equally or more effective
than IV rehydration 92% (45/49) and less
effective in 8% (4/49). Parent satisfaction
was measured with 90% rating satisfied
or extremely satisfied with the procedure and 94% (45/48) felt the procedure
was successful and would select that
method for future rehydration. Safety and
tolerability: Four patients complained
of insertion site pain, others reactions
rated as minimal swelling, erythema and
tenderness. Adverse events occurred in 9
patients, most were considered related to
the child’s illness; one had cellulitis at the
insertion site 20 hours after the removal
of the catheter. Conclusion: SCRT is
safe, effective, easy and rapid option for
rehydration that is well tolerated by both
parents and patients.
II
VI
Subcutaneous Rehydration Therapy
Allen, C. H., Etzwiler,
L. S., Miller, M. K.,
Maher, G., Mace, S.,
Hostetler,…, Harb, G.
(2009). Recombinant
human hydraluronidaseenabled subcutaneuos
pediatric rehydration.
Pediatr, 124(5):e858-67.
doi:10.1542/peds.
2008-3588
Assess efficacy, safety and
clinical utility of recombinant
human hyaluronidase
facilitated rehydration
in children 2 months to 10
years old.
Design: Multicenter single arm pilot
study. IRB approved from each site.
Sample: N=51 children between ages 2
months and 10 years, weight less than 42
kg, with symptoms of dehydration and
need for parenteral fluids. Children with
severe dehydration, shock or life threatening illness were excluded. Setting:
Nine US hospital based EDs.
Measures: The efficacy
primary endpoint was
adequate rehydration from
the ED without requiring
alternative treatment modalities. Secondary efficacy
was change in hydration
symptoms. Ease of use was
measured by time from
initial catheter placement
until infusion began,
the number of attempts
required to place catheter,
and the number of site
changes or interruptions in
flow. Safety and tolerability
was measured by infusion
site pain, reactions or any
adverse events. Statistical
Analysis: Descriptive statistics were used and reported
in frequency tables.
26
CLINICAL PRACTICE GUIDELINE:
Difficult Intravenous Access
Appendix 1: Evidence Table
Reference
Kuensting, L. L. (2013).
Comparing subcutaneous fluid infusion with
intravenous fluid infusion
in children.
J Emerg Nurs, 39(1):8691. doi:10.1016/j.
jen.2012.04.017
Remington, R., &
Hultman, T. (2007).
Hypodermoclysis to treat
dehydration:
A review of the evidence.
J Am
Geriatr Soc, 55(12):20515. doi: 10.1111/j.15325415.2007.01437.x
Research/Purpose
Questions/Hypothesis
Purpose - Evaluate difference
in infusion start time and # of
attempts between initial SC
and IV infusions. Also, if SC
fluids were initially started
was PIV access improved?
Primary objective of this review was to assess the safety
and efficacy of hypodermoclysis (HDC) in the treatment
of mild to moderate dehydration. Secondary object was
to compare HDC to IV fluid
replacement for feasibility.
Design/Sample
Setting
Design: Retrospective descriptive study.
Sample: medical records were reviewed
for 36 children from November 2008 to
May 2010 who had received SC fluids
only or received SC fluids after 2 or
more failed IV attempts. Setting: Large
suburban pediatric ED
One systematic review; two randomized
controlled trials; six cohort studies.
Sample: 2 RCTs and 6 cohort studies
were reviewed. Subjects were elderly,
with a mean age of 71 to 85 years.
Setting: Residents were in long-term
care centers, acute geriatric units, hospice, and/or palliative care environment.
Variables/Measures
Analysis
Findings/Implications
Quality of
Evidence
(4-point scale)*
Level of
Evidence
(7-point scale)**
Primary outcomes were
order time to infusion start
time, number of SC and IV
attempts, disposition.
Statistical analysis:
Frequency distributions;
Mann-Whitney and Wilcoxon tests
Findings: The IV/SC group had significantly longer time to infusion
(M = 97.33 minutes) than did the SC
group (M = 20.95 minutes; U =
.000; P < .001). The IV/SC group included the number of needle sticks for the intravenous attempts plus the needle stick
needed for the subcutaneous infusion. A
significant difference was found between
the 2 groups (mean IV = 4.87; mean SC =
1; Z = .000; P < .001).
Conclusion: In a child who is not seriously ill, SC infusions appear to facilitate
the initiation of parenteral rehydration.
SC infusions minimized the number of
needle sticks a child endured. More study
is needed to determine if SC
fluids enhance success of subsequent
venous cannulation.
II
VI
Measured the safety,
efficacy and feasibility of
HDC vs IV therapy and
HDC alone.
Safety: HDC found to be comparable to
IV administration. Systemic adverse
effects incidence and major local adverse effects did not differ between the
two groups. Mild local adverse effects
occurred more frequently with IV than
HDC. Efficacy: HDC and IV equally
effective. More subjects improved clinically and generally with IV than with
HDC, though not statistically significant. Improvement in lab indicators of
dehydration was similar in both groups.
II
V
27
CLINICAL PRACTICE GUIDELINE:
Difficult Intravenous Access
Appendix 1: Evidence Table
Reference
Spandorfer, P. R., Mace, S.
E., Okada, P. J., Simon, H.
K., Allen, C. H., Spiro, D.
M., ... & Group, S. (2012).
A randomized clinical trial
of recombinant human
hyaluronidase-facilitated
subcutaneous versus intravenous rehydration in mild
to moderately dehydrated
children in the emergency
access: a meta-analysis
and systematic review.
Clin Ther, 34(11):2232-45.
doi:10.1016/j.clinthera.2012.09.011
Research/Purpose
Questions/Hypothesis
Design/Sample
Setting
Objective: This Phase IV
noninferiority trial evaluated
whether rHFSC fluid administration can be given safely
and effectively, with volumes
similar to those delivered
intravenously, to children
who have mild to moderate
dehydration.
Design: Prospective randomized
controlled study.
Methods: The study included mild to
moderately dehydrated children (Gorelick
dehydration score) aged 1 month to 10
years. They were randomized to receive
20 mL/kg of isotonic fluids using rHFSC
or IV therapy over 1 hour and then as
needed until clinically rehydrated.
Sample: 148 children age 1 month 10 years. Setting: 28 US hospitals and
one urgent care clinic
Variables/Measures
Analysis
Findings/Implications
Quality of
Evidence
(4-point scale)*
Level of
Evidence
(7-point scale)**
Primary Outcomes: Mean
total volume infused in
one infusion; secondary
outcomes are total infusion
volume, administration
time, improvement in
dehydration scores,
and pain. Statistics:
descriptive statistics
Findings: In mild to moderately
dehydrated children, rHFSC was
inferior to IV hydration for the primary
outcome measure. However, rHFSC was
noninferior in the ED phase of hydration.
Additional benefits of rHFSC included
time and success of line placement, ease
of use, and satisfaction. SC hydration
facilitated with recombinant human
hyaluronidase represents a reasonable
addition to the treatment options for
children who have mild to moderate
dehydration, especially those with
difficult IV access.
II
III
TFindings: Dry heat was 2.7 times more
likely to result in successful IV insertion.
The difference in mean insertion time
between dry heat (98.5 seconds, SD
= 57.6) and moist heat (127.6 seconds,
SD = 86.1) was considered clinically
meaningful. Moist heat had greater
increase in temperature than dry heat
(p < 0.001) when applied to hand or
forearm. Participants rated higher
anxiety for dry heat (17, SD=22.2)
compared to moist heat (10.9, SD 15.6).
Participants rated comfort significantly
higher for dry heat -8.32) compared
to moist heat (-4.41) (p= 0.0159).
Conclusions: dry heat preferred due to
low cost, safety to patients
and feasibility.
I
II
Warming
Fink, R. M., Hjort, E.,
Wenger, B., Cook, P.
F., & Cunningham, M.
(2009). The impact of
dry versus moist heat on
peripheral iv catherter
insertion in a hematology-oncology outpatient
population. Oncol Nurs
Forum, 36(4):E198-E204.
doi:10.1188/09.ONF.
E198-E204
To determine whether dry
versus moist heat application
to the upper extremity
improves IV insertion rates.
Design: Two-group, randomized,
controlled. IRB approved.
Methods: Towels were heated using
Gentinge 5524 warming cabinet to 160
°F for dry heat and the Equipro Spa-Cabi
61101 (Sundries Novelty Inc) to 178 ° F
for moist heat. Skin temperature monitored using Mon-a-therm 4070 (Nellcor
Puritan Bennett LLC). Sample: N=136
adult hematologic adult outpatients with
cancer or other malignancies.
Setting: An academic cancer infusion
center in Colorado.
Measures: Number of IV
insertion attempts, time
to achieve IV insertion
postheating, patient anxiety
levels pre- and postheating,
and patient comfort.
Statistical Analysis:
Descriptive analysis, t-tests,
chi-square. ANCOVA.
28
CLINICAL PRACTICE GUIDELINE:
Difficult Intravenous Access
Appendix 1: Evidence Table
Reference
Huff, L., Hamlin, A., Wolski,
D., McClure, T., & Eliades,
A. B. (2009). Atraumatic
care: EMLA cream and
application of heat to facilitate
peripheral venous cannulation
in children. Issues
Compr Pediatr Nurs, 32(2):6576. doi:10.1080/014608
60902737418
Lenhardt, R., Seybold, T.,
Kimberger, O., Stoiser,
B., & Sessler, D. I. (2002).
Local warming and insertion of peripheral venous
cannulas: single blinded
prospective randomised
cntrolled trial and single
blinded randomised
crossover trial. BMJ,
325(7361):1-4.
Research/Purpose
Questions/Hypothesis
Investigate whether the
application of heat placed to a
child’s potential intravenous
(IV) site after the application
of EMLA Cream™ decreases
vasoconstriction, as a method
to promote atraumatic
care in the hospitalized
pediatric patient.
Determine whether local
warming of lower arm and
hand facilitates peripheral
venous access
Design/Sample
Setting
Variables/Measures
Analysis
Findings/Implications
Quality of
Evidence
(4-point scale)*
Level of
Evidence
(7-point scale)**
Design: Descriptive. IRB approved.
Informed consent obtained from parent/
legal guardian for all subjects.
Assent was sought from subjects aged
10 - 12 years.
Sample: convenience sample (n=30)
Caucasian children ranging in age from
8 - 12 years, with medical or surgical
diagnoses requiring IV insertion and
who were hospitalized on the school-age
unit at a children’s hospital.
Exclusions: non-Caucasian, developmentally delayed, and dehydrated or
those requiring vasoactive meds.
Setting: 250-bed pediatric hospital.
Measures: WONG baker
faces pain scale. IV Size
measured by SonoSite
iLook 25. Warming device
was DeRoyal infant heel
warmer. PI developed Vein
Visibility Scale to assess
the difficulty of vein visualization (1 = easily visible,
2 = somewhat visible,
and 3 = not visible). Vein
visibility was assessed prior
to EMLA Cream application, one hour after EMLA
Cream, and two minutes
after heat application of
EMLA cream to evaluate
the effectiveness of heat
on vein size and visibility.
Statistical Analysis: a one
way repeated measures
ANOVA was used for the
two outcome variables.
Findings: The overall differences in
average vein measurement across the
three times was statistically significant:
F (2.58) = 30.4, p = 0. The overall
differences in average visualization
across the three times was statistically
significant (F (2.58) = 40.02, p = 0).
The study had an 80% first cannulation
rate. The baseline mean vein size was
0.243cm which decreased to 0.205cm
after EMLA cream application, with
heat application the vein size increased
to 0.253cm. This corresponded to
increased vein size and visibility when
heat applied which counteracted the
vasoconstrictive effect of EMLA.
Conclusion: The application of heat
counteracts the vasoconstriction
associated with EMLA cream.
II
IV
Measures: 1) success rate
of 18 gauge cannula into
hand, 2) time for success
cannulation.
Statistical Analysis:
Unpaired two tailed t tests
and chi square. p<.05 sig.
difference
Findings: Neurosurgical patients had
36 seconds insertion time with active
warming group and 62 seconds in the
passive warming group (P=0.002).
Three (6%) first attempts failed in the
active warming group compared with
14 (28%) in the passive insulation group
(P=0.008). The crossover study with
haematology patients resulted in insertion time was reduced by 20 seconds
(P=0.013) with active warming and that
failure rates at first attempt were 6%
with warming and 30% with passive
insulation (P < 0.001).
Conclusion: Active warming improves
first time cannulation success
with reduced time and number of
required attempts.
II
II
Design: Single blinded prospective
randomized controlled trial and single
blinded randomized crossover trial.
IRB approved. Methods: Neurosurgical
patients had carbon fiber warming device
(PI developed) applied for 15 minutes.
Patients randomly assigned to have
warmer powered on for study, control
was not powered on. Haematology
patients had 10 minute intervention.
Sample: Adult neurosurgical patients
(N=100) and leukemia patients (N=40).
Setting: neurosurgical and haematology
units in a university hospital ward.
29
CLINICAL PRACTICE GUIDELINE:
Difficult Intravenous Access
Appendix 1: Evidence Table
Reference
Research/Purpose
Questions/Hypothesis
Design/Sample
Setting
Variables/Measures
Analysis
Findings/Implications
Quality of
Evidence
(4-point scale)*
Level of
Evidence
(7-point scale)**
Alternative Methods
Chapman, L. L., Sullivan,
B., Pacheco, A. L.,
Draleau, C. P., & Becker,
B. M. (2011). VeinViewer assisted Intravenous
Catheter Placement in
a Pediatric Emergency Department. Acad
Emerg Med, 18(9):96671. doi:10.1111/j.15532712.2011.01155.x
Perry, A. M., Caviness, A.
C., & Hsu, D. C. (2011).
Efficacy of a near-infrared
light device in pediatric
intravenous cannulation:
a randomized controlled
trial. Pediatr Emerg Care,
27(1):5-10. doi: 10.1097/
PEC.0b013e3182037caf
Simhi, E., Kachko, L.,
Bruckheimer, E., &
Katz, J. (2008). A vein
entry indicator device
for facilitating peripheral
intravenous cannulation
in children: a prospective,
randomized, controlled
trial. Anesth Analg,
107(5):1531-5. doi:10.1213/
ane.0b013e318185cdab
Hypothesis: VeinViewer will
decrease time to PIV placement, number of attempts, and
pain in pediatric ED.
Design - randomized controlled trial.
IRB approved. Method: children aged 0
to 17 years who required a nonemergent
PIV in a tertiary care pediatric ED were
randomized to one of two groups-PIV
cannulation (SC) or PIV cannulation
with the VeinViewer (VV). Pediatric
emergency nurses placed all IVs. Data
was collected by an observing research
assistant. N= 323. Setting: Midsize urban
tertiary pediatric ED
Measures: Primary end
points were time to
successful PIV, number
of attempts, pain level.
Patient characteristics
also reviewed.
Statistical Analysis: Two
sample t test, anova,
appropriately powered.
Findings: No significant differences
in standard cannulation (SC) and
VeinViewer (VV). Findings could relate
to skill and experience level of nurses.
Decreased time to cannulation in < 2
years group. Conclusion: Skill level of
nurses may have influenced results.
VV may be more effective in a nonpediatric ED or with less experienced
nurses. Further studies needed to explore
<2yr group
I
II
Determine if use of near
infrared light (VeinViewer, Luminetx Corporation,
Memphis TN) venipuncture
aid would improve the rate
of successful first attempt
placement of IV catheters by
nurses as defined as clinically
important difference of 20%.
Design: Non blinded, randomized
controlled trial. IRB approved. Sample:
N=123 patients younger than 20 years
whose clinical presentation required
IVs stratified to three groups by RN
experience of 5 year intervals then
randomized to (62) standard (control)
or (61) device (infrared)
Setting: Urban pediatric ED
Measures: Time required to
successfully cannulate vein,
primary outcome measure
was first attempt success
rate. Statistical Analysis:
frequencies and CI
Findings: The first attempt success
rate was not significantly different with
the use of near infrared light compared
to no light.
II
II
Number of attempts to
successful IV cannulation;
rate of success at first
attempt; and time required
for IV cannulation. VEID is
a small box with a pressure
sensor that fits onto an IV
cannula. When a change
in pressure in the needle
indicates penetration of
the vessel, a continuous
beep in audible reducing
the likelihood of exiting
the back wall of the vein.
Data analyzed with BMDP
Statistical software.
P value <0.05.
Overall time to cannulation of the vein
was a mean time of 9.1 seconds in the
VEID group and 22.5 in the control
group. Successful cannulation was
attained on the first attempt in 91% of
the VEID group and 69% in the control
group. Average number of attempts in
the VEID group was 1.1 and 1.34 in
the control group. NOTE: Device not
available in the U.S.
II
II
Does use of a vein entry
indicator device (VEID)
facilitate peripheral IV
access in children?
Randomized PIVC with the VEID or
standard PIVC; 22G cannula inserted
into an extremity. One senior pediatric
anesthesiologist evaluated the vein
selected; a second cannulated;
a third recorded results.
Sample: 202 well children in same day
surgery. Ages 3 mos. to 17 yrs.
Setting: Major tertiary hospital.
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CLINICAL PRACTICE GUIDELINE:
Difficult Intravenous Access
Appendix 1: Evidence Table
Reference
Szmuk, P., Steiner, J., Pop,
R. B., Farrow-Gillespie,
A., Mascha, E. J., &
Sessler, D. I. (2013). The
VeinViewer vascular
imaging system worsens
first-attempt cannulation
rate for experienced nurses
in infants and children
with anticipated difficult
intravenous access.
Anesth Analg, 116(5):108792. doi: 10.1213/
ANE.0b013e31828a739e
Research/Purpose
Questions/Hypothesis
Hypothesis: VeinViewer
improves cannulation success
by skilled nurses in pediatric
patients with anticipated DIV
access. Also, look at obesity
and cannulation success.
Design/Sample
Setting
Design: Prospective randomized
controlled trial. IRB approval waived.
Methods: Patients aged 0 to 18 years
were randomized to VeinViewer
or traditional IV. All cannulations
were performed by members of the
Intravenous Access Team.
Sample: N= 600
Setting: Large urban pediatric
medical center
Variables/Measures
Analysis
Findings/Implications
Quality of
Evidence
(4-point scale)*
Level of
Evidence
(7-point scale)**
Primary Outcomes:
First attempt success;
secondary outcome impact
of obesity on success rates
Statistics: Cochran-MantelHaenszel test; MV
logistic regression
Two hundred ninety-nine patients (49%)
were randomly assigned to VeinViewer
and 301 (51%) to routine cannulation.
First-attempt cannulation success was
47% in patients assigned to VeinViewer
vs 62% in patients assigned to routine
cannulation, with an adjusted relative
“risk” (95% confidence interval), of
0.76 (0.63-0.91). The Z-statistic of −3.6
crossed the “harm” boundary (Z <
−2.41), with corresponding P value of
0.0003. The trial was stopped on statistical grounds since the harm boundary for
the primary outcome was crossed. There
was no association between first-attempt
success. Conclusion: The VeinViewer
worsened first-attempt IV insertion
success by skilled nurses. Surprisingly,
first-attempt success for IV cannulation
was not worsened by obesity.
II
II
*Grading the Quality of the Evidence
Acceptable Quality: No Concerns
Limitations in Quality: Minor flaws or inconsistencies in the evidence
Major Limitations in Quality: Many flaws and inconsistencies in the evidence
Not Acceptable: Major flaws in the evidence
**Grading the Levels of the Evidence (Melnyk & Fineout-Overholt, 2005)
Evidence from a systematic review or meta-analysis of all relevant randomized controlled trials or evidence-based clinical practice guidelines based on systematic reviews of RCTs
Evidence obtained from at least one properly designed randomized controlled trial
Evidence obtained from well-designed controlled trials without randomization
Evidence obtained from well-designed case control and cohort studies
Evidence from systematic reviews of descriptive and qualitative studies
Evidence from a single descriptive or qualitative study
Evidence from opinion of authorities and/or reports of expert committees
31
CLINICAL PRACTICE GUIDELINE:
Difficult Intravenous Access
Appendix 2: Other Resources Table
Reference
Description
Conclusions About Blood Culture Contamination
Ultrasound-guided Intravenous Access
Au, A. K., Rotte, M. J., Grzybowski, R. J., Ku, B. S., & Fields, J. M.
(2012). Decrease in central venous catheter placement due to use of
ultrasound guidance for peripheral intravenous catheters.
Am J Emerg Med, 30(9):1950-4. doi:10.1016/j.ajem.2012.04.016
Objective: Quantify reduction in CVC line
placement through USGPIV placement.
USGPIV placement resulted in a reduction in CVC line placement of 85%. The
researchers concluded that USGPIV reduces the need for CVC line placement and
may reduce the number of attempts in DIVA patients.
Chiao, F. B., Resta-Flarer, F., Lesser, J., Ng, J., Ganz, A., Pino-Luey, D.,
... & Witek, B. (2013). Vein visualization: patient characteristic factors
and efficacy of a new infrared vein finder technology. Br J Anaesth,
110(6):966-971. doi:10.1093/bja/aet003
Objective: To determine if infrared technology will
allow for finding of more potential cannulation sites.
Also, identify characteristics of DIV.
African-American or Asian ethnicity, and obesity were associated with decreased
vein visibility. The visibility of veins eligible for cannulation increased for all
subgroups using a new infrared device.
Elia, F., Ferrari, G., Molino, P., Converso, M., De Filippi, G., Milan, A., &
Aprà, F. (2012). Standard-length catheters vs long catheters in ultrasound-guided peripheral vein cannulation. Am J Emerg Med, 30(5):712-6.
doi:10.1016/j.ajem.2011.04.019
Objective: To compare short cath (SC) and long cath
(LC) USG IV failure rates and determine if USG
LC IV cannulation have longer survival rates.
Success rate was 86% in the SC groups and 84% in the LC group (P = .77). Time requested to positioning venous access resulted to be shorter for SC as opposed to LC
(9.5 vs 16.8 minutes, respectively; P = .001). Catheter failure was observed in 45% of
patients in the SC group and in 14% of patients in the LC group (relative risk, 3.2; P b
.001). Both SC and LC US-guided cannulations have a high success rate in patients
with difficult venous access.
Fields, J. M., Todman, R. W., Anderson, K. L., Panebianco, N. L., &
Dean, A .J. (2010). Early failure of ultrasonography-guided peripheral
intravenous catheters in the emergency department: it’s not just about
getting the IV - it’s about keeping it. Ann Emerg Med, 56(3):S75-6.
doi:10.1016/j.annemergmed.2010.06.277
Objective: To determine the effect of vessel depth,
diameter, and location on early failure of US guided
PIV in the ED.
11% failed within 4 hours and 24% failed within 12 hours. Vessel depth was an
independent predictor of early failure; odds ratio 1.7 for each 0.2 cm increase in
depth. 0% early failure for vessels below 0.6 cm; 10% for vessels 0.6 to 0.99 cm; and
27% for vessels 1 cm or greater. For overall US guided IV placement, vessel depth
and location were both independent predictors. 34% failure rate when placed in the
arm compared to 7% failure when placed in or distal to the antecubital fossa.
Mahler, S. A., Wang, H., Lester, C., & Conrad, S. A. (2008). Ultrasound-guided peripheral intravenous access in the emergency department
using modified Seldinger technique: a novel technique. Ann Emerg Med,
52(4):S147. doi:10.1016/j.annemergmed.2008.06.372
Objective: To describe a novel technique of ultrasound guided (US) IV placement. The basilic vein
was cannulated with dynamic guidance of the high
frequency linear probe ultrasound with transverse
probe orientation. Seldinger technique was used to
insert the cannula into the vein over a wire.
Successful cannulation in 96% of the patients. Mean number of needle sticks was
1.32. Mean time from skin to catheter insertion was 86 seconds. Mean total procedure time was 524 seconds (8 minutes 44 seconds). IVs were rechecked 1 hour after
insertion, with 18/20 still being patent. Mean score on satisfaction was 9.38 on a
1-10 Likert scale.
Mahler, S. A., Wang, H., Lester, C., Skinner, J., Arnold, T. C., & Conrad,
S. A. (2011). Short-vs long-axis approach to ultrasound-guided peripheral
intravenous access: a prospective randomized study. Am J Emerg Med,
29(9):1194-7. doi: 10.1016/j.ajem.2010.07.015
Objective: To determine if the short-axis approach
and the long-axis approach to US guided IV
access differ.
A total of 40 patients were enrolled. Median insertion time was 34 seconds (interquartile range, 35 seconds) for the short-axis group compared with 91 seconds (interquartile range, 59 seconds) for the long-axis group (P = .02). Mean number of needle
sticks was 1.5 (±SD 0.7) in the short-axis group compared with 1.4 (±SD 0.7) in the
long-axis group (P = .82). Short axis took less time and had a higher success rate.
Review article
Provides a history of US-guided IV cannulation, how the program was implemented, and
a discussion of key factors to success. In conclusion, US-guided IV cannulation increases
patient satisfaction, decreased nurse/physician frustration, resulted in a cost and time
savings, and reduced complications related to a reduced number of central lines.
Miles, G., Salcedo, A., & Spear, D. (2011). Implementation of a successful registered nurse peripheral ultrasound-guided intravenous catheter
program in an emergency department. J Emerg Nurs, 38(4):353-6.
doi:10.1016/j-jen.2011.02.011
32
CLINICAL PRACTICE GUIDELINE:
Difficult Intravenous Access
Appendix 2: Other Resources Table
Reference
Description
Conclusions About Blood Culture Contamination
Panebianco, N. L., Fredette, J. M., Szyld, D., Sagalyn, E. B., Pines, J.
M., & Dean, A. J. (2008). Ultrasound-guided peripheral intravenous
access: patient pain, anxiety and preference. Ann Emerg Med, 52(4):S61.
doi:10.1016/j.annemergmed.2008.06.127
Objective: To study pain and anxiety levels in patients with difficult IV access who have US guided
IVs, and their preference for US guided IVs.
Pain with US guided IV (1= almost no pain to 5= extremely painful) with successful
IV on 3 attempts was 1.82 vs. 2.55 without successful IV. Pain in IV access without
US was 1.86 with successful IV vs. 2.6 without successful IV. Anxiety with US was
2.51 with successful IV vs 2.7 without success. 6.6% would not want US guided IV
placement in the future. Of failed IV placement, 92.7% would still want US-guided
IV placement in the future.
Sturges, Z., White, S., Barton, E., Battaglia, D., & McCowan, C. L.
(2007). Ultrasound-guided peripheral intravenous access by emergency medical technicians. Ann Emerg Med, 50(3):S87-8. doi:10.1016/j.
annemergmed.2007.06.264
Objective: To test the feasibility of EMTs to use
ultrasound (US) for the placement of peripheral
IV's(PIV) for patients in the ED.
US Guided group: Time to IV placement was 10.8 ± 6.15 minutes; 55.7% described
as difficult access. First attempt success 93.4%, second was 98.4%. Average 1.15
± 0.48 PIV attempts. Satisfaction with the PIV access was 9 ± 1.74 (Likert scale of
1-10). Baseline time to blind PIV placement is not addressed. 76.5% success on first
attempt, 88.2% within 2 attempts, 92.2% within 3 attempts. Satisfaction on blind
PIV attempt was 5.93 ±2.87.
White, A., Lopez, F., & Stone, P. (2010). Developing and sustaining an
ultrasound guided peripheral intravenous access program for emergency
nurses. Adv Emerg Nurs J, 32(2):173-88.
Literature review
Provides an overview of the benefits of US-guided peripheral intravenous access and
outlines the process used at Duke Medical Center for training emergency nurses on
the use of ultrasound-guided venous cannulation.
Objective: To assess the feasibility of EMTs use of
US guided PIV placement for patients in the ED
with difficult IV access.
Average time spent on IV access was 14.95 + 7.45 minutes. 95.6% were considered difficult IV access. 22.2% had one blind IV attempt prior to US; 24.4% had 2
attempts; 40% had 3 attempts; 13.3% had > 3 attempts. Success with US guided PIV
was 75.6% on first attempt; 95.6% on second attempt. Average 1.29 + 0.56 attempts
with US. Patient satisfaction with US guided was 8.9 + 2.5 vs 4.0 + 2.5 for blind IV
attempt (1-10 Likert scale).
White, S., Sturges, Z., Barton, E., Battaglia, D., & McCowan, C. L.
(2007). Ultrasound-guided peripheral intravenous access by emergency
medical technicians in patients with difficult venous access.
Ann Emerg Med, 50(3):S85. doi:10.1016/j.annemergmed.2007.06.256
Intraosseous Vascular Access
Fowler, R., Gallagher, J. V., Isaacs, S. M., Ossman, E., Pepe, P., & Wayne,
M. (2007). The role of intraosseous vascular access in the out-of-hospital
environment (resource document to NAEMSP position statement).
Prehosp Emerg Care, 11(1):6. doi: 10.1080/10903120601021036
Review article
Review of intraosseous vascular access in the out-of-hospital arena. Reviews the
types of IO available, insertion sites, training requirements, success rates, and
limitations of treatment.
Langley, D. M., & Moran, M. (2008). Intraosseous needles: they're
not just for kids anymore. J Emerg Nurs, 34(4):318-9. doi:10.1016/j.
jen.2007.07.005
Case study
Review of two adult cases where intraosseous was utilized. Includes indications
for use, complications, and precautions.
MacKinnon, K.A. (2009). Intraosseous vascular use at signature
healthcare Brockton Hospital Department of Emergency Services.
J Emerg Nurs, 35(5):425-8. doi: 10.1016/j.jen.2009.01.016
Review article
History of intraosseous (IO) including physiology of the vascular structure of the
bone, indications for use, use of blood for laboratory testing, and removal.
Protocol changes have resulted in IO being a front line consideration.
National Association of EMS Physicians. (2006). Position Paper:
Intraosseous Vascular Access in the Out-of-Hospital Setting. Lenexa, KS:
Author. Retrieved from http://www.naemsp.org/MDC%20References%20
for%20Website/IntraosseousVascularAccessintheoutofhospitalsetting.pdf
Position paper of the NAEMSP
Position paper supporting the use of IO access in the out-of-hospital setting.
Recommendation that EMS agencies provide at least one method of IO access
for pediatric patients and should consider IO access for adult patients.
33
CLINICAL PRACTICE GUIDELINE:
Prevention of Blood Culture Contamination
Appendix 2: Other Resources Table
Reference
Description
Conclusions About Blood Culture Contamination
Rouhani, S., Meloney, L., Ahn, R., Nelson, B.D., & Burke, T.F. (2011).
Alternative rehydration methods: A systematic review and lessons
for resource-limited care. Pediatrics, 127(3):e748-57. doi: 10.1542/
peds.2010-0952
Analysis of the effectiveness of non-oral and nonintravenous methods of rehydration. Review of
Medline, Cochrane, Global Health, Embase, and
CINAHL databases for articles on intraosseous,
nasogastric, intraperionteal, subcutaneous, and rectal
rehydration through December 2009. 38 articles; 3
on subcutaneous rehydration; 12 on NG rehydration;
7 on intraperitoneal rehydration; 16 on intraosseous
rehydration; none on protoclysis. Patients less than
18 years of age. Included case reports and consensusbased guidelines. Articles were not excluded based
on quality of methods
SCRT- 3 articles, 2 of which were from the 1960s
Goal: Compare the pharmacokinetics of IO vs IV
administered morphine sulfate.
No significant difference between the IV and IO route on plasma morphine
concentration vs sampling time or pharmocokinetic parameters. Conclusion: Routes
are essentially equivalent. Statistically significant difference in the volume
of distribution in the central compartment (P=0.0247) thought to be due to deposition
effect near the IO port or in the bone marrow.
Von Hoff, D. D., Kuhn, D. G., Burris, H. A., & Miller. L. J. (2008). Does
intraossesous equal intravenous? A pharmacokinetic study. Am J Emerg
Med, 26(1):31-38. doi: 10.1016/j.ajem.2007.03.024
Subcutaneous Rehydration Therapy
Kuensting, L. L. (2011). Subcutaneous infusion of fluid in children.
J Emerg Nurs, 37(4):346-9. doi:10.1016/j-jen.2011.02.
Spandorfer, P. R. (2011). Subcutaneous rehydration: Updating a
traditional technique. Pediatr Emerg Care, 27(3):230-6. doi: 10.1097/
PEC.0b013e31820e1405
Review article
Provides an indepth review of subcutaneous rehydration therapy (SCRT) including
anatomy and physiology, site selection, actions of hyaluronidase, and questions from
a nursing and parent standpoint.
Review article
First reports of hypodermoclysis or subcutaneous rehydration therapy (SCRT) date
back to 1913. Widespread use continued for both adults and children until the 1950s
when sporadic complications were reported related to hypotonic fluid administration
and inappropriate volumes. An IV catheter is placed in the subcutaneous tissues; fluids
are absorbed into the vascular space. Advantages include ease of administration.
Warming
Dillon, F. (2007). Concerns about the use of forced-air warming to
facilitate intravenous cannulation: Don’t “hose” the patient.
Anesthesia & Analgesia, 104(3), 739-740.
doi: 10.1213/01.ane.0000253913.77092.9b
Letter to the editor
The authors warns of the potential for adverse effects of using forced air to warm
the extremity of a patient to facilitate IV cannulation. This off-label use of forced air
warming known as “hosing” is potentially dangerous to patients.
Food and Drug Administration (FDA), FDA Patient Safety News. (2002).
Burns from Misuse of Forced-Air Warming Devices. Show #9, October.
Retrieved from http://www.accessdata.fda.gov/scripts/cdrh/cfdocs/psn/
printer.cfm?id=56
Bulletin
Warning bulletin regarding the practice of using forced air warming without a blanket,
called “hosing” or “free hosing” and the resulting first, second and third degree burns
that have resulted. Further information can be found at “stophosing.com”.
34
CLINICAL PRACTICE GUIDELINE:
Difficult Intravenous Access
Appendix 2: Other Resources Table
Reference
Description
Conclusions About Blood Culture Contamination
Wax, D. (2007). Difficult intravenous access: second thoughts. Anesth
Analg, 104(3):739. doi:10.1213/01.ane.0000253915.99006.24
Letter to the editor
Practice of “hosing” (providing warmed air onto a concentrated extremity with
a goal of dilating the vessels) has resulted in patient burns. This subject is
addressed by the Food and Drug Administration safety alert.
Alternative Methods
Policy statement from ACEP
Alternative methods to difficult venous access must be available and their usage should
be part of the standard emergency medicine privileges. Alternative methods include
intraosseous access, external jugular lines and illumination. Policy and procedures
should allow for non-physician practitioners to establish access via alternate routes
when indicated. Policy should include training requirements.
Eldridge, D. L. (2010). Alternatives to intravenous rehydration in
dehydrated pediatric patients with difficult venous access.
Pediatr Emerg Care, 26(7):529-35. doi:10.1097/PEC.0b013e3181e5c00e
Review article
Article describes the difficult venous access in children including stress of the
procedure on patients, parents and staff. Average, 2.35 attempts to place an IV was
required. 53% of IVs were successful on the first attempt. Average time to place an IV
was 20 minutes. Patient factors related to difficult access including size of the patient,
age, quality of veins, history of prematurity, and poor vein visibility. Very brief review
of alternatives including SCRT, IO, NG, and oral rehydration.
Kuensting, L. L., DeBoer, S., Holleran, R., Shultz, B. L., & Steinmann,
R.A. (2009). Difficult venous access in children: taking control.
J Emerg Nurs, 35(5):419-24. doi:10.1016/j.jen.2009.01.014
Review article
Difficult venous access is prevalent in the pediatric population. Special techniques
should be used to improve success rates. If unsuccessful after 2-4 attempts
alternative methods should be sought.
Larsen, P., Eldridge, D., Brinkley, J., Newton, D., Goff, D., Hartzog, T., ...
Perkin, R. (2010). Pediatric peripheral intravenous access: does nursing
experience and competence really make a difference?. J Infus Nurs,
33(4):226-35. doi: 10.1097/NAN.0b013e3181e3a0a8
Primary Objective: Describe the number of attempts
and the amount of time required to cannulate a
peripheral IV in hospitalized children by a general
pediatric nurse.
Secondary Objective: Determine the amount of
time and the number of venipuncture attempts to
successfully cannulate a peripheral vein, in relation
to nurse and patient characteristics.
Difficult venous access is prevalent in the pediatric population. Special techniques
should be used to improve success rates. If unsuccessful after 2-4 attempts
alternative methods should be sought.
Nafiu, O. O., Burke, C., Cowan, A., Tutuo, N., Maclean, S., & Tremper,
K. K. (2010). Comparing peripheral venous access between obese and
normal weight children. Paediatr Anaesth, 20(2):172-6. doi:10.1111/j.14609592.2009.03198.x
Evaluate relationship between BMI and ease of
venous access in children undergoing non cardiac
surgical procedures
PIV cannulation was achieved on the first attempt in 55.2% while 39.6% of patients
had 2-3 attempts before successful cannulation. Obese children were more likely to
have failed attempt at first cannulation than lean controls (P < 0.001). Obese children
were more likely to require two or more attempts at cannulation than lean children (P <
0.001). The most successful site for obese children after a failed attempt in the dorsum
of the hand is the volar surface of the wrist.
Rauch, D., Dowd, D., Eldridge, D., Mace, S., Schears, G., & Yen, K.
(2009). Peripheral difficult venous access in children. Clin Pediatr (Phila),
48(9):895-901. doi: 10.1177/000992809335737
Review article summarizes recommendation of
consensus panel for physicians. Endorsed by ACEP.
Early recognition of difficult venous access should motivate caregivers to seek
alternatives to PIV when feasible.
American College of Emergency Physicians. (2011). Policy Statement:
Alternative Methods to Vascular Access in Emergency Departments.
Retrieved from http://www.acep.org/Content.aspx?id=80618
35
CLINICAL PRACTICE GUIDELINE:
Difficult Intravenous Access
Appendix 2: Other Resources Table
Reference
Description
Conclusions About Blood Culture Contamination
Yen, K., Riegert, A., & Gorelick, M. H. (2008). Derivation of the DIVA
score: a clinical prediction rule for the identification of children with
difficult intravenous access. Pediatr Emerg Care, 24(3):143-7. doi:10.1097/
PEC.0b013e3181666f32
To develop a clinical prediction rule (DIVA
Score) that would be easy to apply and be useful
for predicting success or failure of peripheral
intravenous line insertion in children.
A clinical prediction rule was created to apply as predictor of success or failure of PIV
access. Success rate of 75% first attempt. Using DIVA score pt with 4 or greater were
more than 50% likely to have failed IV attempt.
Alternative Methods
Riker, M. W., Kennedy, C., Winfrey, B. S., Yen, K., & Dowd, M. D.
(2011). Validation and refinement of the difficult intravenous access
score: a clinical prediction rule for identifying children with difficult
intravenous access. Acad Emerg Med, 18(11):1129-34. doi: 10.1111/j.15532712.2011.01205.x
Objective: To validate and possibly refine Yen’s
DIVA score rule.
Study validated Yen’s DIVA score rule. Four variables were associated with failed IV
placement (age, vein visibility, vein palpability, and prior NICU stay). Three variables
provided comparable outcomes to the four variable rule - palpability, visibility and age;
nurse confidence level was on the only nursing characteristic with statistically significant
findings. More confident nurses were less likely to have a failed IV attempt.
Sebbane, M., Claret, P. G., Lefebvre, S., Mercier, G., Rubenovitch, J.,
Jreige, R., ... de La Coussaye, J. E. (2013). Predicting peripheral venous
access difficulty in the emergency department using body mass index and
a clinical evaluation of venous accessibility. J Emerg Med, 44(2):299-305.
doi: 10.1016/j.jemermed.2012.07.051
Objective: To investigate the relationship between
BMI and PIV access difficulty in an ED setting and
identify patient-related predicting factors.
Peripheral lines were placed in 563 consecutive patients (53 ± 23 years, BMI: 26 ±
7 kg/m2), with a success rate of 98.6%, and a mean attempt of 1.3 ± 0.7 (range 1-7).
Obese and underweight patients were more likely to have a failed IV attempt on first
attempt than normal weight patients.
Witting, M. D. (2012). IV access difficulty: incidence and delays in an
urban emergency department. J Emerg Med, 42(4):483-7.
Objective: Estimate the incidence of IV access
difficulty and its associated delays in the ED.
In an urban ED mild to moderate IV access difficulty was common and led to minor
delays, severe IVAD resulted in significant delays.
36
CLINICAL PRACTICE GUIDELINE:
Difficult Intravenous Access
Appendix 3: Study Selection Flowchart and Inclusion/Exclusion Criteria
Potentially relevant publications identified by
electronic search
(n=244)
Publications excluded as they did not meet
the PICOT question
(n=206)
Publications reviewed in full text
(n=38)
Publications excluded as they did not meet
the PICOT question upon full review
(n=5)
Publications reviewed in full text
(n=33)
Publications excluded (did not meet
evidence analysis criteria)
(n=11)
Potentially that met criteria to be included in
evidence analysis (sound and relevant studies)
(n=13)
Publications not excluded from evidence analysis,
but included as background information
(n=9)
Inclusion Criteria
Exclusion Criteria
Studies published in English
Studies involving human subjects
October 2011- October 2015
Studies addressing the PICOT question
Studies not published in English
Non-human studies
Studies not in the timeframe listed
Studies not addressing the PICOT questions
The following databases were searched: PubMed, Google Scholar, CINAHL, Cochrane - British Medical Journal, Agency for Healthcare Research and Quality (AHRQ;
www.ahrq.gov), and the National Guideline Clearinghouse (www.guidelines.gov).
Search terms included: “difficult intravenous access,” “tools intravenous access,” “heat,” “nitroglycerin,” “tourniquet,” “ultrasound,” “light,” “illumination,” “subcutaneous
rehydration therapy,” and “hypodermoclysis,” “interosseous”, “infrared”, and “ultrasound guided”, using a variety of different search combinations.
37