In patients with limited or difficult venous access, INS emphasizes a structured assessment and the least invasive device that can safely deliver the prescribed therapy, often escalating earlier to midline or central access and using visualization technology to avoid repeated failed PIV attempts. Device choice must integrate therapy characteristics (pH, osmolarity, vesicant status), anticipated duration, vessel quality, and patient specific factors rather than vein availability alone.
Key INS principles
- Perform comprehensive pre-access assessment of all venous sites and create a vascular access plan before attempting cannulation.
- Use vascular visualization to increase insertion success, reduce attempts, and support selection of the most appropriate, least invasive device in difficult venous access (DIVA) patients.
- Escalate early to a vascular access specialist or team when peripheral attempts are unsuccessful or the patient is known/suspected DIVA.
Device selection in limited veins
- Short PIVC: Use only when therapy is short, non-vesicant, and a site “most likely to last” can be identified; avoid repeated up the arm cannulation in fragile or scarce veins.
- Midline catheter: Consider when peripheral veins are limited but therapy is intermediate in duration and appropriate for peripheral administration; reduces repeated venipuncture compared with multiple PIVs.
- PICC or tunneled CVC: Select when therapy is >6 days–2 weeks, vesicant/irritant, or when peripheral options are exhausted or inadequate; central access may be necessary despite vein limitations in the extremities.
Factors INS expects you to weigh
- Therapy: Vesicant/irritant status (e.g., via INS vesicant list), osmolarity, pH, need for TPN, rapid infusion, or blood products.
- Duration: Anticipated length of therapy (hours vs days vs weeks/months) is a key driver of whether PIVC, midline, PICC, tunneled CVC, or port is appropriate.
- Patient and vessel: Age, comorbidities, chronic kidney disease (preservation of upper extremity veins), history of DIVA, number/quality of remaining veins, and patient preference for location.
Practical approach for DIVA/limited veins
- Limit failed PIV attempts and avoid “vein chasing”; move quickly to visualization guided insertion and/or longer term devices when indicated.
- Involve a vascular access specialist or team early to evaluate for midline vs PICC vs tunneled CVC vs port, guided by INS standards and local algorithms.
- Document a long-term vascular access plan to preserve remaining veins and minimize complications.
For a protocol or algorithm, local policies should align with the most recent INS Infusion Therapy Standards of Practice, adapted to your patient population and available technologies.
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References
Nickel, B. et al., (2024, January/ February) Infusion Therapy Standards of Practice 9th edition. Journal of Infusion Nursing. https://www.ins1.org/publications/infusion-therapy-standards-of-practice/