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Pediatric Difficult Intravenous Access Scores in a Low-Resource Setting: An External Validation Study
Panida Kanjanauptom1, David Kessler2, Sirin Khongjaroensakun1
1Department of Pediatrics, Faculty of Medicine Siriraj Hospital, Mahidol University, Bangkok, Thailand.
Insights
A new LMIC-DIVA score effectively identifies difficult intravenous access in children within low-resource settings. This modified score demonstrates superior accuracy compared to existing DIVA scores, improving pediatric emergency care.
Area of Science:
- Pediatric Emergency Medicine
- Vascular Access
- Global Health
Background:
- Difficult intravenous access (DIVA) poses challenges in pediatric emergency care, particularly in low- to middle-income countries (LMIC).
- Existing DIVA scores require validation and potential modification for diverse healthcare settings.
Purpose of the Study:
- To validate pediatric difficult intravenous access (DIVA) scores in LMIC emergency settings.
- To identify factors associated with DIVA for developing an optimized score.
Main Methods:
- Prospective cross-sectional study of 392 children (0-15 years) requiring peripheral intravenous access (PIVA).
- DIVA defined as first-attempt PIVA failure.
- Analysis included ROC curves, logistic regression for predictive factors, and development of the LMIC-DIVA score.
Main Results:
- The difficult intravenous access (DIVA) rate was 30.1%.
- Factors associated with DIVA included vein visibility, vein palpability, younger age, and prior DIVA history.
- The novel LMIC-DIVA score showed superior discriminative ability (AUC 0.79) compared to DIVA3 (AUC 0.65) and DIVA4 (AUC 0.62).
Conclusions:
- The study provides external validation for DIVA3 and DIVA4 in an LMIC context.
- The modified 4-variable LMIC-DIVA score demonstrates improved accuracy for identifying pediatric difficult intravenous access.
- This enhanced score can optimize emergency care in resource-limited settings.
Objectives:
This study aims to establish and evaluate validity data for pediatric difficult intravenous access (DIVA) scores in low-resource emergency care settings within low- to middle-income countries (LMIC). We also sought to explore associated factors for DIVA that could contribute to a modified pediatric DIVA score with optimal performance in our setting.
Methods:
We performed a prospective cross-sectional study in children aged 0 to 15 years who required urgent or emergent peripheral intravenous access (PIVA) over a 10-month period in a large university hospital in Bangkok, Thailand. DIVA was defined as a failure of PIVA on the first attempt. For each candidate DIVA model, receiver operating characteristic curves were constructed, and the area under the curves was calculated. Additional candidate predictive factors of patients and providers were collected and analyzed using a logistic regression model.
Results:
Among a convenience sample of 392 children enrolled, the DIVA rate was 30.1%. Three-variable DIVA (DIVA3) and 4-variable DIVA scores (DIVA4) demonstrated similar test characteristics in our population in identifying patients with first attempt failure rate of at least 50%. Vein visibility, vein palpability, younger age, and history of DIVA were statistically significant factors related to DIVA. Through the inclusion of 4 factors associated with DIVA, the LMIC-DIVA score was developed and exhibited superior discriminative ability compared with the DIVA3 and DIVA4 scores. The area under the curves for LMIC-DIVA, DIVA3, and DIVA4 were 0.79 (95% CI=0.74-0.83), 0.65 (95% CI=0.59-0.70), and 0.62 (95% CI=0.56-0.67), respectively.
Conclusion:
This study provides external validation data for DIVA3 and DIVA4 scores in the LMIC setting. The novel modified 4-variable LMIC-DIVA score improves test characteristics and accuracy in identifying pediatric DIVA in our population.
