{"status":"ok","message-type":"work","message-version":"1.0.0","message":{"indexed":{"date-parts":[[2026,10,10]],"date-time":"2026-10-10T18:02:57Z","timestamp":1791655377994,"version":"4.3.4"},"reference-count":33,"publisher":"MDPI AG","issue":"3","license":[{"start":{"date-parts":[[2026,3,23]],"date-time":"2026-03-23T00:00:00Z","timestamp":1774224000000},"content-version":"vor","delay-in-days":0,"URL":"https:\/\/creativecommons.org\/licenses\/by\/4.0\/"}],"content-domain":{"domain":[],"crossmark-restriction":false},"short-container-title":["Medicina"],"abstract":"<jats:p>Background and Objectives: Difficult venous access (DVA) affects 10\u201326% of hospitalized patients and up to 60% in high-risk populations, leading to increased patient discomfort, delayed diagnosis, and substantial healthcare costs estimated at $4.7 billion annually in the United States. This meta-analysis aimed to systematically evaluate the effectiveness, safety, and implementation considerations of traditional and emerging strategies for obtaining blood samples in patients with DVA. Materials and Methods: We conducted a comprehensive systematic review and meta-analysis following PRISMA guidelines. We searched MEDLINE, Embase, CINAHL, and Cochrane databases from January 2016 to December 2023. Inclusion criteria encompassed randomized controlled trials, systematic reviews, and observational studies examining DVA interventions in adult and pediatric populations. Primary outcomes included first-attempt success rates, overall success rates, and complication rates. Statistical analysis used random-effects models with risk ratios and 95% confidence intervals. Results: Forty-seven studies involving 12,847 patients met the inclusion criteria. Technology-assisted approaches demonstrated superior outcomes compared to traditional techniques. Ultrasound guidance showed the highest effectiveness with a first-attempt success increase of 42% (RR 1.42, 95% CI 1.26\u20131.58, p &lt; 0.001), followed by near-infrared visualization with a 28% increase (RR 1.28, 95% CI 1.14\u20131.42, p &lt; 0.001). Population-specific approaches yielded significant benefits, including the use of scalp veins for infants and external jugular approaches for extreme DVA cases. Cost-effectiveness analysis revealed that ultrasound guidance achieved break-even within 8\u201314 months in high-volume centers. Conclusions: A systematic, stepwise approach integrating appropriate technology and techniques significantly improves success rates while reducing patient discomfort and healthcare costs. Healthcare institutions should implement comprehensive DVA protocols with adequate training, equipment access, and quality monitoring. The proposed algorithm achieved a 93% overall success rate in validation studies, representing a substantial improvement over traditional approaches.<\/jats:p>","DOI":"10.3390\/medicina62030604","type":"journal-article","created":{"date-parts":[[2026,3,23]],"date-time":"2026-03-23T13:07:06Z","timestamp":1774271226000},"page":"604","update-policy":"https:\/\/doi.org\/10.3390\/mdpi_crossmark_policy","source":"Crossref","is-referenced-by-count":2,"title":["Strategies to Address Difficult Venous Access in Blood Sampling: A Comprehensive Meta-Analysis"],"prefix":"10.3390","volume":"62","author":[{"ORCID":"https:\/\/orcid.org\/0000-0002-0550-1002","authenticated-orcid":false,"given":"Baudolino","family":"Mussa","sequence":"first","affiliation":[{"name":"Surgical Science Department, University of Turin, 10124 Turin, Italy"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Gloria","family":"Passarella","sequence":"additional","affiliation":[{"name":"Surgical Science Department, University of Turin, 10124 Turin, Italy"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Mara","family":"Marchese","sequence":"additional","affiliation":[{"name":"Surgical Science Department, University of Turin, 10124 Turin, Italy"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Barbara","family":"Defrancisco","sequence":"additional","affiliation":[{"name":"Surgical Science Department, University of Turin, 10124 Turin, Italy"}],"role":[{"vocabulary":"crossref","role":"author"}]}],"member":"1968","published-online":{"date-parts":[[2026,3,23]]},"reference":[{"key":"ref_1","doi-asserted-by":"crossref","first-page":"2","DOI":"10.1016\/j.jped.2017.07.009","article-title":"Sedation and analgesia for procedures in the pediatric emergency room","volume":"93","author":"Ramalho","year":"2017","journal-title":"J. Pediatr."},{"key":"ref_2","doi-asserted-by":"crossref","first-page":"062604","DOI":"10.1117\/1.JMI.11.6.062604","article-title":"Augmented reality for point-of-care ultrasound-guided vascular access in pediatric patients using Microsoft HoloLens 2: A preliminary evaluation","volume":"11","author":"Zhang","year":"2024","journal-title":"J. Med. Imaging"},{"key":"ref_3","doi-asserted-by":"crossref","first-page":"182","DOI":"10.5301\/jva.5000487","article-title":"Insertion of peripheral intravenous cannulae in the emergency department: Factors associated with first-time insertion success","volume":"17","author":"Carr","year":"2016","journal-title":"J. Vasc. Access"},{"key":"ref_4","doi-asserted-by":"crossref","first-page":"e3428","DOI":"10.1097\/MD.0000000000003428","article-title":"Development of the A-DIVA scale: A clinical predictive scale to identify difficult intravenous access in adult patients based on clinical observations","volume":"95","author":"Puijn","year":"2016","journal-title":"Medicine"},{"key":"ref_5","doi-asserted-by":"crossref","unstructured":"van Loon, F.H.J., van Hooff, L.W.E., de Boer, H.D., Koopman, S.S.H.A., Buise, M.P., Korsten, H.H.M., Dierick-van Daele, A.T.M., and Bouwman, A.R.A. (2019). The Modified A-DIVA Scale as a Predictive Tool for Prospective Identification of Adult Patients at Risk of a Difficult Intravenous Access: A Multicenter Validation Study. J. Clin. Med., 8.","DOI":"10.3390\/jcm8020144"},{"key":"ref_6","doi-asserted-by":"crossref","first-page":"321","DOI":"10.5301\/jva.5000346","article-title":"Ultrasound-guided peripheral venous access: A meta-analysis and systematic review","volume":"16","author":"Stolz","year":"2015","journal-title":"J. Vasc. Access"},{"key":"ref_7","first-page":"18","article-title":"Ultrasound-guided peripheral venous access: A systematic review of randomized-controlled trials","volume":"21","author":"Liu","year":"2014","journal-title":"Eur. J. Emerg. Med."},{"key":"ref_8","doi-asserted-by":"crossref","first-page":"1204","DOI":"10.1177\/11297298231154297","article-title":"Cost effectiveness of ultrasound-guided long peripheral catheters in difficult vascular access patients","volume":"25","author":"Bahl","year":"2024","journal-title":"J. Vasc. Access"},{"key":"ref_9","doi-asserted-by":"crossref","unstructured":"Fehr, G., Rigali, M., Weller, G., Grap, S.M., Coleman, M., Parekh, U., Chinchilli, V.M., and Dalal, P.G. (2023). Efficacy of Infrared Vein Visualization versus Standard Technique for Peripheral Venous Cannulation in Infant and Toddler Populations: A Randomized Study. Children, 10.","DOI":"10.3390\/children10101652"},{"key":"ref_10","doi-asserted-by":"crossref","first-page":"103553","DOI":"10.1016\/j.iccn.2023.103553","article-title":"Facilitators and barriers to evidence-based practice in central venous access device insertion and management in an intensive care unit: A qualitative study","volume":"80","author":"Lin","year":"2024","journal-title":"Intensive Crit. Care Nurs."},{"key":"ref_11","doi-asserted-by":"crossref","first-page":"1847","DOI":"10.1515\/cclm-2022-0567","article-title":"Arterial and venous blood sampling is equally applicable for coagulation and fibrinolysis analyses","volume":"60","author":"Christensen","year":"2022","journal-title":"Clin. Chem. Lab. Med."},{"key":"ref_12","doi-asserted-by":"crossref","first-page":"401","DOI":"10.1016\/j.jemermed.2007.02.027","article-title":"Predictors of Success in Nurse-Performed Ultrasound-Guided Cannulation","volume":"33","author":"Chinnock","year":"2007","journal-title":"J. Emerg. Med."},{"key":"ref_13","doi-asserted-by":"crossref","first-page":"6","DOI":"10.1177\/17449871231213025","article-title":"The economic burden of difficult intravenous access in the emergency department from a United States\u2019 provider perspective","volume":"29","author":"Gala","year":"2024","journal-title":"J. Res. Nurs."},{"key":"ref_14","doi-asserted-by":"crossref","first-page":"106","DOI":"10.1097\/NAN.0000000000000579","article-title":"Impact of the Warm Compress Method Conducted by Nurses Before Venipuncture on Blood Nitric Oxide Concentration","volume":"48","author":"Koike","year":"2025","journal-title":"J. Infus. Nurs."},{"key":"ref_15","doi-asserted-by":"crossref","unstructured":"Pan, C.-T., Francisco, M.D., Yen, C.-K., Wang, S.-Y., and Shiue, Y.-L. (2019). Vein Pattern Locating Technology for Cannulation: A Review of the Low-Cost Vein Finder Prototypes Utilizing near Infrared (NIR) Light to Improve Peripheral Subcutaneous Vein Selection for Phlebotomy. Sensors, 19.","DOI":"10.3390\/s19163573"},{"key":"ref_16","doi-asserted-by":"crossref","first-page":"444","DOI":"10.1016\/j.annemergmed.2012.11.014","article-title":"Ultrasonographically guided peripheral intravenous cannulation of children and adults: A systematic review and meta-analysis","volume":"61","author":"Heinrichs","year":"2013","journal-title":"Ann. Emerg. Med."},{"key":"ref_17","doi-asserted-by":"crossref","first-page":"1950","DOI":"10.1016\/j.ajem.2016.06.098","article-title":"A randomized controlled trial assessing the use of ultrasound for nurse-performed IV placement in difficult access ED patients","volume":"34","author":"Bahl","year":"2016","journal-title":"Am. J. Emerg. Med."},{"key":"ref_18","doi-asserted-by":"crossref","unstructured":"Sou, V., McManus, C., Mifflin, N., Frost, S.A., Ale, J., and Alexandrou, E. (2017). A clinical pathway for the management of difficult venous access. BMC Nurs., 16.","DOI":"10.1186\/s12912-017-0261-z"},{"key":"ref_19","first-page":"CD005179","article-title":"Psychological interventions for needle-related procedural pain and distress in children and adolescents","volume":"10","author":"Birnie","year":"2018","journal-title":"Cochrane Database Syst. Rev."},{"key":"ref_20","doi-asserted-by":"crossref","first-page":"975","DOI":"10.1503\/cmaj.150391","article-title":"Reducing pain during vaccine injections: Clinical practice guideline","volume":"187","author":"Taddio","year":"2015","journal-title":"Can. Med Assoc. J."},{"key":"ref_21","doi-asserted-by":"crossref","first-page":"521","DOI":"10.1136\/emermed-2012-201652","article-title":"Ultrasound guidance for difficult peripheral venous access: Systematic review and meta-analysis","volume":"30","author":"Egan","year":"2013","journal-title":"Emerg. Med. J."},{"key":"ref_22","doi-asserted-by":"crossref","first-page":"84","DOI":"10.17085\/apm.22171","article-title":"Retrospective analysis of the feasibility and safety of external jugular vein cannulation in surgical patients","volume":"18","author":"Ju","year":"2023","journal-title":"Anesth. Pain Med."},{"key":"ref_23","doi-asserted-by":"crossref","first-page":"65","DOI":"10.1017\/S1049023X21001217","article-title":"Comparison of standard technique, ultrasonography, and near-infrared light in difficult peripheral vascular access: A randomized controlled trial","volume":"37","author":"Akarca","year":"2022","journal-title":"Prehospital Disaster Med."},{"key":"ref_24","unstructured":"Cho, C., Koser, B.W., and Das, J.M. (2025, December 16). Scalp Vein Catheterization, StatPearls [Internet], Available online: https:\/\/www.ncbi.nlm.nih.gov\/books\/NBK565911\/."},{"key":"ref_25","doi-asserted-by":"crossref","first-page":"6624","DOI":"10.1038\/s41598-020-63771-5","article-title":"A clinical rule for the difficulty prediction on scalp intravenous access in infants","volume":"10","author":"Wei","year":"2020","journal-title":"Sci. Rep."},{"key":"ref_26","doi-asserted-by":"crossref","first-page":"e67918","DOI":"10.2196\/67918","article-title":"Effects of Cold and Vibration on Venipuncture Pain Management in Children Aged 2-7 Years Old: Randomized Controlled Trial","volume":"8","author":"Zhou","year":"2025","journal-title":"JMIR Pediatr. Parent."},{"key":"ref_27","doi-asserted-by":"crossref","first-page":"237","DOI":"10.1097\/NAN.0000000000000338","article-title":"A Comparative Study of Blood Sampling from Venipuncture and Short Peripheral Catheters in Pediatric Inpatients","volume":"42","author":"Twibell","year":"2019","journal-title":"J. Infus. Nurs."},{"key":"ref_28","doi-asserted-by":"crossref","first-page":"S1","DOI":"10.1097\/NAN.0000000000000396","article-title":"Infusion Therapy Standards of Practice, 8th Edition","volume":"44","author":"Gorski","year":"2021","journal-title":"J. Infus. Nurs."},{"key":"ref_29","doi-asserted-by":"crossref","first-page":"1105","DOI":"10.1007\/s00134-012-2597-x","article-title":"International evidence-based recommendations on ultrasound-guided vascular access","volume":"38","author":"Lamperti","year":"2012","journal-title":"Intensive Care Med."},{"key":"ref_30","doi-asserted-by":"crossref","first-page":"347","DOI":"10.1038\/sj.bmt.1704357","article-title":"Efficacy and safety of femoral vascular access for peripheral blood stem cell (PBSC) collection","volume":"33","author":"Albo","year":"2004","journal-title":"Bone Marrow Transplant."},{"key":"ref_31","doi-asserted-by":"crossref","first-page":"18","DOI":"10.1097\/00152193-200407000-00017","article-title":"Tips for inserting an IV in an older patient","volume":"34","author":"Moureau","year":"2004","journal-title":"Nursing"},{"key":"ref_32","doi-asserted-by":"crossref","first-page":"42","DOI":"10.3892\/mi.2025.241","article-title":"Venous access devices (Review)","volume":"5","author":"Abdulelah","year":"2025","journal-title":"Med. Int."},{"key":"ref_33","doi-asserted-by":"crossref","first-page":"2565","DOI":"10.1364\/BOE.7.002565","article-title":"Augmented reality based real-time subcutaneous vein imaging system","volume":"7","author":"Ai","year":"2016","journal-title":"Biomed. Opt. Express"}],"container-title":["Medicina"],"original-title":[],"language":"en","link":[{"URL":"https:\/\/www.mdpi.com\/1648-9144\/62\/3\/604\/pdf","content-type":"unspecified","content-version":"vor","intended-application":"similarity-checking"}],"deposited":{"date-parts":[[2026,3,23]],"date-time":"2026-03-23T13:42:03Z","timestamp":1774273323000},"score":1,"resource":{"primary":{"URL":"https:\/\/www.mdpi.com\/1648-9144\/62\/3\/604"}},"subtitle":[],"short-title":[],"issued":{"date-parts":[[2026,3,23]]},"references-count":33,"journal-issue":{"issue":"3","published-online":{"date-parts":[[2026,3]]}},"alternative-id":["medicina62030604"],"URL":"https:\/\/doi.org\/10.3390\/medicina62030604","relation":{},"ISSN":["1648-9144"],"issn-type":[{"value":"1648-9144","type":"electronic"}],"subject":[],"published":{"date-parts":[[2026,3,23]]}}}