PIVC Difficult IV access

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Difficult Intravenous Access – The daily challenge to hospital staff

Establishing functional peripheral intravenous access is a routine activity in both the emergency department and inpatient setting. While the traditional method of vein palpation for cannulation is successful in the majority of patients, patients with difficult intravenous access (DIVA) present a challenge that hospital staff must address on a daily basis.1

Difficult (peripheral) intravenous access is generally understood as arising when two or more punctures are performed without success, or when puncture support methods are required, or when the impossibility of obtaining peripheral access means that a central venous catheter (CVC) must be inserted.2, 3, 4

They all search for deep veins

Difficult IV access (DIVA) can be expected in the following patients: 2, 3

  • Pediatric patients and neonates
  • Overweight and obese patients 
  • Old and chronically ill patients, e. g. those suffering from diabetes 
  • Emergency and acute care patients who have, for example, skin burns, hematomas, or dehydration

Did You Know?

A difficult IV access is not uncommon. In fact, more than 30% of adults and up to 50% of children requiring a PIVC are found to have a challenging venous access.

In addition, approximately one-third of critically ill patients are in the group for whom intravenous access can be challenging. These are often patients with generalized edema, obese patients, patients with multiple prior cannulations, or patients who use intravenous drugs. Conventional techniques often fail in these patient groups.5

Catheter-related complications further complicate the situation, with an average of 43% of all IV catheters failing.6

In pediatric patients, approximately one-quarter of initially successfully placed IV Catheters had to be removed before the end of therapy due to device failure. This included infiltration at 14.3%, followed by accidental dislodgement (5%) and blockage (2.6%).

There are a few related characteristics of the cannulated vessel and vascular access device that impact catheter survival: depth of vein, amount of catheter residing in vein, a length of the vascular access.1

Difficult IV accesses take time

The average time required for a peripheral intravenous cannulation is reported to be 2.5 to 13 minutes. Having a difficult IV access it takes up to 30 minutes.3

Causes and Challenges

Overall, the group of patients who are potential candidates for DIVA is large: Neonates and pediatric patients, overweight and obese patients, elderly and chronically ill patients, and acute patients.2, 3

In neonates and pediatric patients, the success rate of correctly placing the catheter on the first puncture is less than 35% due to thicker tissue layers.8 Overall, up to 50% of pediatric patients are considered as DIVA.2

In overweight and obese patients, multiple attempts are usually necessary due to the thicker subcutaneous adipose tissue layer, which in turn is associated with two risks.8, 9 First, the puncture error rate increases, and second, the risk of infiltration is increased. According to the WHO, obesity has nearly tripled worldwide since 1975 and is expected to increase further in Europe.10, 11 Already, 47.6% of European adults are considered overweight and 12.8% are obese.12

Elderly and chronically ill patients, such as those suffering from diabetes, have weaker vascular systems. In the U.S., 14.5% of people are over 65 years old, and 422 million suffer from diabetes.13

Injuries in emergency and acute care patients, such as skin burns, hematomas, or dehydration, result in difficult intravenous access in approximately 11% of all patients.14

„Patients with difficult IV access are frequently subjected to repeated attempts by multiple practitioners. Success rate and time to vascular cannulation are crucial to the optimal resuscitation of a critically ill patient. This can be challenging to even the most experienced emergency nurse.”3


Difficult IV access is usually associated with repeated insertion attempts and catheter-related complications. These are not only time-consuming and material-intensive, but also lead to an increased stress level among the nursing staff and the patient, combined with an increased perception of pain.

Repeated insertion attempts

In the emergency department in particular, the problem of DIVA has been found to negatively impact both patient safety and satisfaction. For example, multiple failed attempts to insert vascular access often result in patients becoming increasingly agitated, exhibiting "needle phobia", and losing trust in healthcare professionals. Patients may develop pain or bruising at the insertion sites, putting them at higher risk for skin injury and infection. Delayed access can further increase the time needed for necessary diagnoses or treatments such as fluid resuscitation and administration of medications or pain medications.2

Complementing this, multiple punctures may be associated with progressive deterioration of the vascular tree, termed "vascular exhaustion", which further complicates vascular access during successive contacts with the patient.15

Catheter-related complications

Once cannulated, survival of IV catheters is problematic, with early failure being a common complication.16 

Nearly 40% of PIVC are terminated early due to complications such as dislocation and infiltration. Dislocation is when the catheter loses access to the patient's vasculature and causes a forced, premature interruption of infusion therapy. Infiltration, on the other hand, occurs when punctures do not properly target the vascular access and cause the infused solution to flow into the tissue surrounding the vascular access. This complication is particularly relevant when infusing highly irritating (e.g., vesicant) substances.6

In addition to nerves and time, repeated insertion attempts cost material above all. For example, the average cost of replacing PIVCs per sequence of IV treatment is USD 51.92.17

Repeated unsuccessful insertion of a PIVC sometimes leads to switching to more expensive and complex solutions and using central venous catheters (CVC) or peripherally inserted central catheters (PICC). Both alternatives require a longer insertion process and are associated with higher material costs. However, in many cases, CVCs are inserted unnecessarily. Although patients are eligible for a peripheral IV catheter, CVC or PICC are used because of difficult IV access rather than dwell time or infusion solution.18

Preventive Strategies

To treat patients with difficult intravenous access in a time-, nerve-, and material-conserving manner, the use of longer PIVC and ultrasound-assisted catheter insertion is recommended.

Longer length PIVC

A longer part of the capillary tubing stays in the vein and helps to prevent catheter dislodgements and infiltrations.19, 20, 21, 22

It also increases the survival time of the catheter. According to calculations, the optimal length of the catheter in the vein is at least 2.75 cm. Longer length PIVC have a survival time of 129 hours (5.4 days) compared to shorter catheters of 75 hours (3.1 days).16

”A PIVC of appropriate size (gauge and length) should be selected depending on the patient’s veins: the diameter (gauge) is important for patients with very thin veins, while the length is important for obese patients with deep-seated veins.”23

”Longer PIVCs have been observed to have a decreased incidence of infiltration and extravasation, which is especially important when infusing highly irritant (e.g. vesicant) substances.”24

Ultrasound-guided catheter

To identify peripheral vessels and assist in vein cannulation in patients with challenging vein access, ultrasound (US) may be useful.25

“Long catheter US-guided procedure is associated with a lower risk of catheter failure compared with short catheter US-guided procedure.”25

“A longer extended dwell catheter represents a viable and favorable alternative to the standard longer IVs used for US-guided cannulation of veins >1.20 cm in depth. These catheters have significantly improved survival rates with similar insertion success characteristics.”1

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Scientific Evidence


1 Bahl A, Hang B, Brackney A, Joseph S, Karabon P, Mohammad A, ... & Shotkin P. Standard long IV catheters versus extended dwell catheters: A randomized comparison of ultrasound-guided catheter survival. The American journal of emergency medicine. 2019;37(4);715-721.
2 Whalen M, Maliszewski B, Baptiste DL. Establishing a Dedicated Difficult Vascular Access Team in the Emergency Department: A Needs Assessment. J Infus Nurs. 2017 May/Jun;40(3):149-154.
3 Crowley M, Brim C, Proehl J, Barnason S, Leviner S, Lindauer C, Naccarato M, Storer A, Williams J, Papa A. Emergency nursing resource: difficult intravenous access. Journal of emergency nursing. 2012 Jul 1;38(4):335-43.
4 Rodríguez-Calero MA, Blanco-Mavillard I, Morales-Asencio JM, Fernández-Fernández I, Castro-Sánchez E, de Pedro-Gómez JE. Defining risk factors associated with difficult peripheral venous Cannulation: A systematic review and meta-analysis. Heart & Lung. 2020 May 1;49(3):273-86.
5 Blanco P. Ultrasound-guided peripheral venous cannulation in critically ill patients: a practical guideline. The ultrasound journal. 2019 Dec;11(1):1-7.
6 Helm RE, Klausner JD, Klemperer JD, Flint LM, Huang E. Accepted but unacceptable: peripheral IV catheter failure. J Infus Nurs. 2015 May-Jun;38(3):189-203
7 Malyon L, Ullman AJ, Phillips N, Young J, Kleidon T, Murfield J, Rickard CM. Peripheral intravenous catheter duration and failure in paediatric acute care: A prospective cohort study. Emerg Med Australas. 2014 Dec;26(6):602-8
8 Nafiu OO, Burke C, Cowan A, Tutuo N, Maclean S, Tremper KK. Comparing peripheral venous access between obese and normal weight children. Paediatr Anaesth. 2010 Feb;20(2):172-6
9 Fields JM, Piela NE, Ku BS. Association between multiple IV attempts and perceived pain levels in the emergency department. J Vasc Access. 2014;15:514–8
10 WHO Obesity and overweight https://www.who.int/news-room/fact-sheets/detail/obesity-and-overweight
11 Pineda E, Sanchez-Romero LM, Brown M, Jaccard A, Jewell J, Galea G, Webber L, Breda J. Forecasting Future Trends in Obesity across Europe: The Value of Improving Surveillance. Obes Facts. 2018;11(5):360-71.
12 Gallus S, Lugo A, Murisic B, Bosetti C, Boffetta P, La Vecchia C. Overweight and obesity in 16 European countries. Eur J Nutr. 2015 Aug;54(5):679-89
13 Wengström Y, Margulies A; European Oncology Nursing Society Task Force. European Oncology Nursing Society extravasation guidelines. Eur J Oncol Nurs. 2008 Sep;12(4):357-61
14 Dychter Samuel S. MD, Gold David A PhD, Carson Deborah RN, Haller, Michael PhD. Intravenous Therapy: A Review of Complications and Economic Considerations of Peripheral Access. Journal of Infusion Nursing. 2012 Mar;35(2);84-91.
15 Moraza-Dulanto MI, Garate-Echenique L, Miranda-Serrano E, Armenteros-Yeguas V, Tomás-López MA, Benítez-Delgado B. Inserción eco-guiada de catéteres centrales de inserción periférica (PICC) en pacientes oncológicos y hematológicos: éxito en la inserción, supervivencia y complicaciones. Enferm Clin. 2012;22(3);135–143
16 Bahl, A., Hijazi, M., Chen, N.W., Clavette-Lachapelle, L. and Price, J., 2019. Ultra Long versus Standard Long Peripheral Intravenous Catheters: A Randomized Controlled Trial of Ultrasound-Guided Catheter Survival. Available at SSRN 3401988 
17 Marsh N, Webster J, Larson E, Cooke M, Mihala G, Rickard CM. Observational Study of Peripheral Intravenous Catheter Outcomes in Adult Hospitalized Patients: A Multivariable Analysis of Peripheral Intravenous Catheter Failure. J Hosp Med. 2018 Feb 1;13(2):83-89
18 Paladini A, Chiaretti A, Sellasie KW, Pittiruti M, Vento G. Ultrasound-guided placement of long peripheral cannulas in children over the age of 10 years admitted to the emergency department: a pilot study. BMJ Paediatr Open. 2018 Mar 28;2(1):e000244
19 Paladini, A., Chiaretti, A., Sellasie, K.W., Pittiruti, M. and Vento, G., 2018. Ultrasound-guided placement of long peripheral cannulas in children over the age of 10 years admitted to the emergency department: a pilot study. BMJ paediatrics open, 2(1).
20 Elia, F., Ferrari, G., Molino, P., Converso, M., De Filippi, G., Milan, A. and Aprà, F., 2012. Standard-length catheters vs long catheters in ultrasound-guided peripheral vein cannulation. The American journal of emergency medicine, 30(5), pp.712-716.
21 Meyer P, Cronier P, Rousseau H, Vicaut E, Choukroun G, Chergui K, Chevrel G, Maury E. Difficult peripheral venous access: clinical evaluation of a catheter inserted with the Seldinger method under ultrasound guidance. Journal of critical care. 2014 Oct 1;29(5):823-7.
22 Scoppettuolo G, Pittiruti M, Pitoni S, Dolcetti L, Emoli A, Mitidieri A, Migliorini I, Annetta MG. Ultrasound-guided “short” midline catheters for difficult venous access in the emergency department: a retrospective analysis. International journal of emergency medicine. 2016 Dec;9(1):1-7.
23 Bertoglio S, van Boxtel T, Goossens GA, Dougherty L, Furtwangler R, Lennan E, Pittiruti M, Sjovall K, Stas M. Improving outcomes of short peripheral vascular access in oncology and chemotherapy administration. J Vascular Access. 2017 Mar 21;18(2):89-96
24 (Department of Health AU, PIVC Guideline) https://www.health.qld.gov.au/__data/assets/pdf_file/0025/444490/icare-pivc-guideline.pdf
25 Fabrizio et al 2011, Standard-length cateter vs long catheters in ultrasound-guided peripheral vein cannulation, American Journal of Emergency Medicine (2012) 30, 712–716