Comparative effectiveness of interventions for difficult intravenous access in adults: A systematic review and...

Difficult intravenous access (DIVA) affects an estimated 8%-39% of hospitalized adults and is associated with treatment delays, increased pain, and elevated healthcare costs. Multiple interventions have been developed to address this challenge, yet, to our knowledge, no network meta-analysis (NMA) has simultaneously compared the full range of available interventions in adult patients.

A systematic search of PubMed, Embase, the Cochrane Library, and Web of Science was conducted from inception through February 1, 2026, for randomized controlled trials comparing any DIVA intervention with standard practice or another active intervention in adults. Primary outcomes were first-attempt and overall success rates. Secondary outcomes included number of attempts, procedure time, pain score, and patient satisfaction. Random-effects NMA was performed using the netmeta package in R. Treatment rankings were summarized using P-scores. Subgroup analyses, meta-regression, sensitivity analyses, and publication bias assessments were conducted.

Twenty-four RCTs (8014 participants) evaluating 11 active interventions were included. For first-attempt success, ultrasound guidance (OR = 5.58; 95% CI: 2.74-11.36) and local warming (OR = 5.72; 95% CI: 1.71-19.19) were significantly superior to standard practice. For overall success, only ultrasound guidance achieved significance (OR = 4.12; 95% CI: 2.07-8.19). Local warming uniquely reduced procedure time and pain, while near-infrared devices reduced cannulation attempts and improved patient satisfaction. Long catheters were associated with increased pain and longer procedure times. Meta-regression identified publication year and DIVA status as significant effect modifiers. No publication bias was detected.

Ultrasound-guided cannulation showed the most consistent benefit for first-attempt and overall success and rested on the strongest evidence base; local warming showed a comparable but less certain effect from limited data. A stratified, context-sensitive approach integrating patient acuity, resource availability, and intervention-specific profiles appears reasonable, although the sparse network and the transitivity assumption temper the certainty of these conclusions.