Pediatric Difficult Intravenous Access Scores in a Low-Resource Setting: An External Validation Study

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.