Introduction
Intravenous cannulation of a peripheral vein is the most common invasive procedure performed in hospitals worldwide.1 The traditional landmark approach involves visual inspection and palpation of the extremity to locate a vein, followed by needle puncture and catheter insertion. The landmark failure rate on first attempt ranges from 12% to 26% among adults and is twice as high in difficult-access patients.2, 3, 4 When multiple cannulation attempts are necessary, patients experience more pain and treatment delays.Editor’s Capsule Summary
What is already known on this topic
Intravenous access is important but without technical aids can sometimes be difficult. Ultrasonography offers an alternative to standard insertion methods.
What question this study addressed
Does ultrasonographically guided intravenous insertion aid in all patients or just those deemed in advance to present more challenging access?
What this study adds to our knowledge
Using a randomized, controlled assignment in 1,189 patients, trained technicians had higher success with landmark approaches in those deemed to have easier access, but ultrasonographic intravenous insertion attempts produced higher success in the moderate- and highest-difficulty groups.
How this is relevant to clinical practice
Selective use of ultrasonographic intravenous placement approaches targeting more difficult patients is pragmatic and evidence based.
Ultrasonography increases the success rate of central venous line placement, especially at the internal jugular site, but studies evaluating ultrasonographic peripheral intravenous line placement have reported inconsistent results.5, 6 Eight randomized controlled trials have compared the initial or final peripheral intravenous line placement success rate between landmark and ultrasonography in difficult-access patients.7, 8, 9, 10, 11, 12, 13, 14 The majority of the trials9, 11, 12, 13, 14 favored ultrasonography and reported clinically meaningful differences of 10% or greater in initial13 or overall success rate.9, 11, 12, 14 However, each study’s results were based on a small sample size (range of 35 to 60 total subjects). Meta-analyses of the trials’ results have reported conflicting findings because of heterogeneous patient populations, varying definitions of difficult access, and operator experience.15, 16, 17 This randomized controlled trial of 1,189 adult emergency department (ED) patients seeks to determine whether the initial peripheral intravenous line placement success rate is higher with landmark or ultrasonography among patients with difficult, moderately difficult, or easy venous access by randomly assigning the procedural method within each difficulty of intravenous access group and operator. We originally hypothesized that the initial success rate would be at least 5% higher when ultrasonography was used among patients with difficult or moderately difficult peripheral intravenous access but no different (ie, <5%) among patients with easy access.