MODERN MANAGEMENT STRATEGIES FOR DIFFICULT INTRAVENOUS ACCESS (DIVA): FROM PREDICTIVE MODELING TO VISUALIZATION TECHNOLOGIES

Abstract

Introduction. Difficult peripheral intravenous access (DIVA) is an independent clinical problem in modern medicine, characterized by the inability or substantial difficulty of peripheral vein cannulation using standard landmark technique (visualization and/or palpation of the vessel) after at least two failed venipuncture attempts by qualified healthcare personnel. Multicenter studies report DIVA prevalence of 10–33% among adult hospitalized patients, reaching 52% in emergency departments (ED) and 69% in children under 1 year of age. The DIVA phenomenon is associated with a doubling of length of stay in the department (increase by 87 min; 95% CI 60–120; p<0.001), delayed initiation of analgesia by 50 min and fluid therapy by 36 min, directly affecting the quality and safety of medical care. Objective. To systematize current evidence on the epidemiology, etiopathogenesis, risk factors, validated prediction scores, and technologies for securing peripheral venous access in patients with DIVA, based on the highest level of evidence (meta‑analyses, systematic reviews, randomized controlled trials) published between 2019 and 2026. Materials and Methods. A systematic analysis was performed of data from meta‑analyses, systematic reviews, and randomized controlled trials (RCTs) indexed in PubMed, Scopus, and Web of Science Core Collection between 2019 and 2026. Search terms included: “difficult intravenous access”, “DIVA”, “DIVA score”, “ultrasound-guided peripheral intravenous catheter”, “near-infrared vein finder”, “vascular access prediction”, “EA DIVA”, “SAFE rule”. Inclusion criteria were: studies involving adult and pediatric patients with confirmed or suspected DIVA; validation studies of prediction scores; comparative studies of vein visualization technologies. Level of evidence was assessed using the Oxford Centre for Evidence- Based Medicine (CEBM) scale and the GRADE system. In total, 87 publications were analyzed, including 15 meta-analyses, 23 systematic reviews, and 34 RCTs with a cumulative sample of over 25,000 patients. Results. DIVA was found to result from a combination of anatomical (vein diameter <3 mm, depth >10 mm), physiological (dehydration, hypovolemia, vasoconstriction), iatrogenic (multiple venipunctures, chemotherapy, prolonged infusion therapy) and clinical–demographic factors (obesity, diabetes mellitus, malignancy, chronic kidney disease, sickle cell disease, intravenous drug use [IVDU]). Multivariable meta-analyses identified 10 key independent predictors of DIVA with OR >2.0 (including absence of visible/palpable veins, history of ≥2 failed attempts, vein depth >10 mm, obesity, malignancy/chemotherapy, IVDU, dehydration, diabetes, CKD/sickle cell disease), which formed the basis for validated risk scores. Adult scores (A DIVA, Modified A DIVA, EA DIVA, C DIVA, SAFE rule) demonstrate AUC 0.80–0.97, sensitivity 70–97%, specificity 75–89%; among them SAFE rule (cutoff ≥2) and EA DIVA (cut-off ≥6–8) show the most favorable sensitivity/specificity balance and are recommended as core bedside tools for screening and risk stratification. Near-infrared (NIR) vein visualization devices showed a moderate but statistically significant benefit, particularly in geriatric, obese, and selected DIVA cohorts: FAS OR ≈2.36; procedure time reduction by ≈30 s; complication rate reduction (OR ≈0.37). In the general pediatric population the effect of NIR is limited; however, in children at high risk of DIVA, FAS increases from ≈25% to ≈58%. Ultrasound-guided peripheral intravenous catheterization (USG PIVC) demonstrated a substantial advantage over standard technique: FAS 90–97% (OR ≈3.0), reduction in mean number of attempts from ≈2.4 to ≈1.1, time-to-success reduction by 3–10 min, and approximately twofold decrease in infiltration and phlebitis rates. In the pediatric DIAPEDUS RCT in children with DIVA, FAS reached 90% with USG versus 18% with landmark technique. Direct comparisons of USG and NIR in DIVA cohorts confirm higher efficacy of USG, whereas NIR functions as a useful adjunct in patients with mild-to-moderate risk. Conclusions. Difficult peripheral intravenous access is a prevalent clinical problem with a frequency of 20–25% in the general hospital population and over 50% in emergency departments, associated with a marked deterioration in timeliness of care, increased complication rates, and higher resource utilization. Integration of validated prediction scores (SAFE rule, EA DIVA) with ultrasound guidance and NIR visualization into standardized clinical protocols enables transformation of DIVA management from a reactive to a predictive approach based on early risk stratification and timely escalation of access methods. Such an approach provides clinically meaningful improvements: increase in first-attempt success rates to 90–97%, reduction in the number of attempts by 57%, decrease in length of stay by 30–87 minutes, reduction in complication rates by 50%, and better patientcentered outcomes (less pain, reduced anxiety, higher satisfaction). Ultrasoundguided cannulation is recommended as a first-line method for patients at high risk of DIVA (EA DIVA ≥6, SAFE ≥2), whereas NIR devices may be used as adjunctive tools in patients with moderate risk or within combined protocols. Implementation of evidence-based DIVA protocols is a priority direction for improving the quality and safety of peripheral venous access in contemporary clinical practice.