**2.6 Patient's medical history**

Medical histories of the individuals, particularly the previous history of difficulty with punctures or insertion of catheters, may be the risk factors for DIVA due to their effect on the vascular structure [13, 14]. Intravenous chemotherapy treatment is one of the most serious causes of the disruption of the vascular structure. Chemotherapy drugs (vesicants, irritants) cause complications such as phlebitis, infiltration, extravasation, thrombophlebitis, and septicemia, manifesting as pain, redness, ulceration, and necrosis along the vein, and stimulate the sympathetic nervous system, thereby causing the vessels to contract and decreasing their fullness and visibility [26]. Similarly, fluids with high osmolarity, the blood, and the blood products may damage the vascular endothelium. Repeated attempts of these treatments may be a risk factor for DIVA [27].

#### **2.7 Vein characteristics**

The vascular structure may differ from individual to individual. The diameter, visibility, palpability, and superficiality (or depth) of the vein are important factors to be considered when determining the appropriate vein for PIVC [8]. A vein with a wide diameter is easily visible and palpable. Van Loon et al. reported that nonpalpable invisible veins and the veins less than 3 mm in diameter after tourniquet application lead to DIVA [13]. Jacobson and Winslow (2005) reported that failed IV insertions were associated with higher degrees of difficulty arising from vein a variable, such as vein rolled or vein was resistant to puncture.

### **3. Factors related to health professionals**

It is reported that difficult peripheral intravenous cannulation affects 10%–24% of all hospitalized adults and is associated with higher rates of catheter failure. This situation may lead to several complications, such as phlebitis, extravasation, hemorrhage, catheter-related infection, and sepsis [6, 18]. In order to prevent these complications, healthcare professionals must be aware of the risk factors for DIVA. The practitioners' knowledge and skill regarding catheter insertion and their clinical experience are the health professional-related factors for difficult cannulation [7, 14]. The literature states that the experience of the practitioner with catheter insertion is associated with forced catheter intervention. Rippey et al. (2016) reported that the practitioner's experience influenced the success of catheter placement in a single attempt [28]. Van Loon et al. (2019) reported that the prediction that the practitioner might have a difficult catheter intervention was associated with DIVA [13]. Rodriguez-Calero et al. (2020) reported no relationship between the clinical experience of the practitioners and DIVA and stated that catheter insertion could only be associated with the patients and their treatment [14].

The success of vascular access and conducting the procedure in a short duration are important for patient safety and satisfaction. Determining the appropriate vein, using the appropriate materials, and placing the catheter with the right technique would make the procedure convenient for both patient and the healthcare professional. Therefore, the practitioners must possess adequate knowledge and skills of cannulation [29, 30].

### **4. Management of difficult venous access**

PIVC is expected to be performed in a single attempt. In the cases where the catheter cannot be inserted in a single attempt, it is recommended to limit the number of insertions by a single practitioner to two [29]. However, this is not possible in certain cases. Therefore, determining the appropriate vein and the appropriate catheter and using the most appropriate technique to access the vein is important for the prevention and control of DIVA caused due to factors related to either the patient or the practitioner [8, 11, 14, 18].

#### **4.1 Assessment of the appropriate vein in difficult venous access**

Determining the appropriate vein prior to catheter insertion is important for performing the procedure conveniently. Plump veins are distinctly visible and palpable, and therefore, easier to detect. In order to determine if the catheter insertion procedure would be challenging, the veins should be graded. Certain vein

#### *Difficult Intravenous Access and Its Management DOI: http://dx.doi.org/10.5772/intechopen.96613*

grading scales have been developed for application in adults and pediatric patients [13, 31, 32]. The Adult Difficult IntraVenous Access (A-DIVA) scale developed and updated by Van Loon et al. (2019) includes a known history of difficult intravenous access, an expectation of difficult intravenous access by the practitioner prior to the intravenous cannulation, the inability to detect a dilated vein through palpation and/or visualization of the extremity, and a target vein diameter of less than 3 mm. A higher score on the A-DIVA scale indicates a higher risk of difficult intravenous access [13] (**Table 1**). In the vein grading scale developed by Lenhardt et al. (2002) the following factors were included: 1) The veins are completely invisible and not palpable; 2) The veins are visible although not palpable; 3) The veins are hardly visible although palpable, 4: The veins are visible and palpable; 5) The veins are distinctly visible and palpable. This scale may be used to evaluate the veins, although access to the veins rated 1 on this scale could be rather difficult [32].

Vein grading/assessment scales for small patient groups are different. The Difficult IntraVenous Access (DIVA) scale developed by Yen et al. (2008) included the visibility and palpability of the vein, and the age, skin color, and premature status of the patients as evaluation parameters. The obtained scores ranged from 0 to 11. If the obtained score was four or higher, it indicated difficult vascular access with a 50% probability of failure [31]. The scale was reviewed by Riker et al. (2011) who reduced the parameters to only 3, namely visibility of vein, palpability of vein, and age of the patient. The scale has also been adapted to the Turkish population by removing the parameter of skin color. The prediction of whether the procedure would be difficult prior to the PIVC is crucial as it prevents possible complications (**Table 2**) [31, 33]. Therefore, it is recommended that healthcare professionals use these scales [29].

The more visible and more palpable the vein preferred for PIVC, the more convenient the procedure would be. Dorsal metacarpal veins, basilica, and cephalic veins are the frequently preferred ones for PIVC. In particular, for ongoing intravenous treatments, the IV entry site should be located distal to the arm, and each attempt should be further proximal compared to the next attempt. Leg and foot veins should be avoided as much as possible due to the risk of lower extremity embolism involved [34]. However, this order of vein preference may change in the cases where veins are not easily visible and palpable. If there is a possibility of difficult cannulation, the upper arm basilica vein should be preferred because of its larger diameter. However, since this vein might be deep-seated, its visibility could be low; in which case; the procedure should be performed using palpation or vein imaging systems [35].

Another frequently preferred vein to avoid difficult venous access is the antecubital vein. The large diameter and the superficial location of this vein render it easily visible or palpable. However, with this vein, catheter stabilization could be difficult as this vein is located in the elbow joint [34]. Panebianco et al. (2009) reported that, with an increase in the diameter of the veins (92% success at 0.6 cm)


#### **Table 1.** *The additive A-DIVA scale [13].*

