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COMMENTARY
Year : 2020  |  Volume : 13  |  Issue : 4  |  Page : 422-423  

Difficult peripheral intravenous access: Need for some light


1 Departments of Onco-Anaesthesiology and Palliative Medicine, Pain Medicine and Critical Care, All India Institute of Medical Sciences, Delhi, India
2 Departments of Anaesthesiology, Pain Medicine and Critical Care, All India Institute of Medical Sciences, Delhi, India

Date of Submission20-Nov-2019
Date of Decision20-Nov-2019
Date of Acceptance03-Dec-2019
Date of Web Publication20-Jul-2020

Correspondence Address:
Nishkarsh Gupta
437 Pocket A, Sarita Vihar, New Delhi - 110 076
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/mjdrdypu.mjdrdypu_316_19

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How to cite this article:
Ahuja D, Gupta N, Gupta A. Difficult peripheral intravenous access: Need for some light. Med J DY Patil Vidyapeeth 2020;13:422-3

How to cite this URL:
Ahuja D, Gupta N, Gupta A. Difficult peripheral intravenous access: Need for some light. Med J DY Patil Vidyapeeth [serial online] 2020 [cited 2020 Aug 6];13:422-3. Available from: http://www.mjdrdypv.org/text.asp?2020/13/4/422/290176



Peripheral venous cannulation is one of the most common and essential procedures performed in inpatient and some selected outpatient patients.[1] The indications for securing intravenous access range from obtaining blood for sampling, administer fluids, intravenous therapy, and resuscitation.[1] The procedure of securing intravenous access can be difficult in about third of adults and half of children presenting to the hospital.[2],[3] The difficulty in cannulation may be anticipated in some patients such as in pediatric age group, obese patients, elderly patients, dark-skinned patients, patients in shock, and patients previously treated with chemotherapy.[4] The simple procedure of taking blood can become more challenging if it is performed repeatedly in these patients. The difficult venous access is characterized by the presence of nonvisible and nonpalpable veins in spite of milking of limb, gentle tapping of skin, overlying skin, use of tourniquet, and application of alcohol and vasodilators, further warranting the help of technological aids for securing vascular access.[5] The difficulty in cannulation can be further exacerbated by venous thrombosis, resulting from repeated venipunctures and increased fragility of veins due to intimal damage following chemotherapy.[4] The difficulty in cannulation not only leads to delay in the diagnosis and institution of treatment but also increases distress of patients and their family members due to the multiple, painful attempts that are required to gain peripheral venous access. The placement of central venous catheter may be considered if there is a failure of placement of peripheral venous access. However, the central venous access device (CVAD) placement is itself associated with a number of complications.[6] Moreover, placement of CVAD may not be solution for all patients as the number of patients encountered with difficult intravenous access is substantial. Thus, the role of judiciously selecting and using patient's intravenous access cannot be overemphasized. To highlight the fact more, Chiao et al. have described the concept of vein preservation, i.e., careful mapping of all superficial veins to choose appropriate cannulation site.[7]

Anesthesiologists play an important role in patients where difficulty in securing intravenous access is encountered. A number of methods have been developed to secure peripheral venous access safely. Initially, devices that used infrared light for transillumination, for example, Veinlite and Venoscope were developed.[8] Subsequently, near-infrared (NIR) technology was developed that utilized the principle of selective absorption of a particular NIR waves by the deoxygenated hemoglobin to display superficial veins (up to 8 mm below the skin). This device helps to visualize the patient's superficial veins and guides clinicians by providing “roadmap” to efficiently gain intravenous access. In addition, VeinViewer® offers the advantage that it renders the hands of the clinician free to deal with venous access as there is no probe or transducer. This technology was initially reported to be clinically useful in the identification of varicose veins that could not be visualized by the naked eye or an ultrasound. Later, different studies reported conflicting results about VeinViewer® facilitating IV access, first-attempt success rates, and total procedure time.[8],[9] However, still some unresolved issues regarding NIR technology such as training operators in use of this technology, lack of availability due to cost, and calculation of learning curve to achieve first-time successful cannulation have made clinical utility less common. Further, multispectral camera and robotic systems have also been used in the management of patients with difficult intravenous access.[9]

Recently, in an article by Bloria et al., the authors have explained about using the flashlight of a mobile, in case difficulty in venous access is encountered.[10] The flashlight uses the principle of transillumination for visualizing the veins. Other devices that use better NIR technology are better and already available. Moreover, instruments such as VeinViewer® help in delineating the entire course of vein rather than just localization of the vein and also give information about depth of the vein from the skin surface. As already mentioned, earlier cannulation time is also an important factor while securing peripheral venous access in a patient. The authors may have found the technique to be successful, but before recommending the technique routinely for all patients with difficult intravenous access, future randomized control trials are required. We should develop an institutional protocol to manage difficult IV access depending on the available clinical evidence, availability of equipment, and expertise [Figure 1].
Figure 1: Suggested protocol for difficult peripheral IV access

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  References Top

1.
Alexandrou E, Ray-Barruel G, Carr PJ, Frost S, Inwood S, Higgins N, et al. International prevalence of the use of peripheral intravenous catheters. J Hosp Med 2015;10:530-3.  Back to cited text no. 1
    
2.
Witting MD. IV access difficulty: Incidence and delays in an urban emergency department. J Emerg Med 2012;42:483-7.  Back to cited text no. 2
    
3.
Whalen M, Maliszewski B, Baptiste DL. Establishing a dedicated difficult vascular access team in the emergency department: A Needs Assessment. J Infus Nurs 2017;40:149-54.  Back to cited text no. 3
    
4.
Lamperti M, Pittiruti M. II. Difficult peripheral veins: Turn on the lights. Br J Anaesth 2013;110:888-91.  Back to cited text no. 4
    
5.
Sebbane M, Claret PG, Lefebvre S, Mercier G, Rubenovitch J, Jreige R, et al. Predicting peripheral venous access difficulty in the emergency department using body mass index and a clinical evaluation of venous accessibility. J Emerg Med 2013;44:299-305.  Back to cited text no. 5
    
6.
Kornbau C, Lee KC, Hughes GD, Firstenberg MS. Central line complications. Int J Crit Illn Inj Sci 2015;5:170-8.  Back to cited text no. 6
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7.
Chiao FB, Resta-Flarer F, Lesser J, Ng J, Ganz A, Pino-Luey D, et al. Vein visualization: Patient characteristic factors and efficacy of a new infrared vein finder technology. Br J Anaesth 2013;110:966-71.  Back to cited text no. 7
    
8.
Miyake RK, Zeman HD, Duarte FH, Kikuchi R, Ramacciotti E, Lovhoiden G, et al. Vein imaging: a new method of near infrared imaging, where a processed image is projected onto the skin for the enhancement of vein treatment. Dermatol Surg 2006;32:1031-8.  Back to cited text no. 8
    
9.
Peled C, Blechman H, Blechman O. Peripheral vein locating techniques. Imaging Med 2016;8.  Back to cited text no. 9
    
10.
Bloria SD, Luthra A, Chauhan R, Bloria P, Kataria K. Using mobile to assist in difficult vein cannulation. Med J DY Patil Vidyapeeth2020;13:420-1.  Back to cited text no. 10
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