Development of the A-DIVA Scale:

Placement of a peripheral intravenous catheter is a routine procedure in clinical practice, but failure of intravenous cannulation regularly occurs. An accurate and reliable predictive scale for difficult venous access creates the possibility to use other techniques in an earlier time frame. We aimed to develop a predictive scale to identify adult patients with a difficult intravenous access prospectively: the A-DIVA scale. This prospective, observational, cross-sectional cohort study was conducted between January 2014 and January 2015, and performed at the department of anesthesiology of the Catharina Hospital (Eindhoven, The Netherlands). Patients 18 years or older were eligible if scheduled for any surgical procedure, regardless ASA classification, demographics, and medical history. Experienced and certified anesthesiologists and nurse anesthetists routinely obtained peripheral intravenous access. Cannulation was performed regarding standards for care. A failed peripheral intravenous cannulation on the first attempt was the outcome of interest. A population-based sample of 1063 patients was included. Failure of intravenous cannulation was observed in 182/1063 patients (17%). Five variables were associated with a failed first attempt of peripheral intravenous cannulation: palpability of the target vein (OR1⁄4 4.94, 95% CI [2.85–8.56]; P< 0.001), visibility of the target vein (OR1⁄4 3.63, 95% CI [2.09–6.32]; P< 0.001), a history of difficult peripheral intravenous cannulation (OR1⁄4 3.86, 95% CI [2.39–6.25]; P< 0.001), an unplanned indication for surgery (OR1⁄4 4.86, 95% CI . M. Puijn, RN, Sa n, PhD, Bouwman, MD attempt in the low-risk group (A-DIVA score 0 or 1), whereas the medium (A-DIVA score 2 or 3) and high-risk group (A-DIVA score 4 plus), included 72/195 (37%) and 74/80 (93%) patients with a failed first attempt of inserting a peripheral intravenous catheter, respectively. The additive 5-variable A-DIVA scale is a reliable predictive rule that implies the probability to identify patients with a difficult intravenous access prospectively. Dutch Trial Register (ref: 4595). (Medicine 95(16):e3428) Abbreviations: A-DIVA scale = Adult Difficult Intravenous Access scale, ASA = American Society of Anesthesiology, AUC = area under the curve, BMI = body mass index, CI = confidence interval, IV = intravenous, NRS = numeric rating scale, ROC curve = receiver operating characteristics curve, SPSS = Statistical Package for the Social Science, TRIPOD = Transparent Reporting of a multivariable prediction model for Individual Prognosis Or Diagnosis. INTRODUCTION P eripheral intravenous cannulation is the most common invasive procedure in clinical practice for administering fluids and medication. Among hospitalized patients, 70% to 80% need a peripheral intravenous catheter. However, as a straightforward and routine procedure, peripheral intravenous access is not easily obtained in all patients. This can be frustrating to medical professionals, but more importantly, it can be a painful, uncomfortable, and stressful experience for an already anxious patient, especially when multiple attempts are necessary. Moreover, multiple unsuccessful attempts to cannulate a peripheral vein create a time-consuming situation and are associated with additional risks as nerve damage, paresthesia, hematoma, and arterial puncture. Successful peripheral intravenous cannulation can be influenced by various factors, such as palpable or visual absence of a vein, as well as diabetes mellitus, sickle cell disease, body habitus, vascular pathology, physician in training, burn injuries, intravenous drug abuse, fluid status, sex, and age. In children, it is possible to predict the likelihood of a failure of intravenous cannulation on the first attempt by using the DIVA scale, a 4-variable proportionally weighted rule. Yen and colleagues reported the DIVA rule to be a useful aid in identifying children who may benefit from interventions that improve success rates of intravenous cannulation, but which are too resource-consuming to be used in all patients. In a subsequent study, Riker and colleagues concluded that the use of the DIVA scale can guide the implementation of adjunctive modalities to assist in obtaining timely vascular access, iatric patients for who traditional techte to increased pain and anxiety, dissad care and delay in treatment. www.md-journal.com | 1 A difficult intravenous access scale for adult patients (ADIVA scale) is currently lacking. Such a scale could be used to prospectively identify patients with a high probability of a difficult intravenous access based on easily available clinical data, which may improve clinical practice and patient’s comfort. In general, prediction models are developed to aid healthcare providers in estimating the probability or risk that a specific outcome is present in patients, and to inform their decisionmaking. When the inserter is not able to locate the target vein using palpitation or visualization, blind cannulation can be performed using landmarks and a trial and error approach. Alternatively, ultrasound provides a useful advanced technique. In addition, an accurate and reliable A-DIVA scale creates the possibility to use other techniques, such as ultrasound or the call for assistance of more-experienced individuals, in an earlier time frame. The aim of this study was to primarily identify risk factors for failure to perform peripheral intravenous cannulation on the first attempt in adult patients. Subsequently, the simplified additive A-DIVA scale creates a possibility to calculate the risk of failure during intravenous cannulation on the first attempt and to classify patients with a difficult intravenous access prospectively.