Ultrasonography-guided peripheral intravenous access versus traditional approaches in patients with difficult intravenous access

Study objective: We assess the success rate of emergency physicians in placing peripheral intravenous catheters in difficult-access patients who were unsuccessfully cannulated by emergency nurses. A technique using real-time ultrasonographic guidance by 2 physicians was compared with traditional approaches using palpation and landmark guidance. Methods: This was a prospective, systematically allocated study of all patients requiring intravenous access who presented to 2 university hospitals between October 2003 and March 2004. Inclusion criterion was the inability of any available nurse to obtain intravenous access after at least 3 attempts on a subgroup of patients who had a history of difficult intravenous access because of obesity, history of intravenous drug abuse, or chronic medical problems. Exclusion criterion was the need for central venous access. Patients presenting on odd days were allocated to the ultrasonographic-guided group, and those presenting on even days were allocated to the traditional-approach group. Endpoints were successful cannulation, number of sticks, time, and patient satisfaction. Results: Sixty patients were enrolled, 39 on odd days and 21 on even days. Success rate was greater for the ultrasonographic group (97%) versus control (33%), difference in proportions of 64% (95% confidence interval [Cl] 39% to 71%). The ultrasonographic group required less overall time (13 minutes versus 30 minutes, for a difference of 17 [95% Cl 0.8 to 25.6]), less time to successful cannulation from first percutaneous puncture (4 minutes versus 15 minutes, for a difference of 11 [95% Cl 8.2 to 19.4]), and fewer percutaneous punctures (1.7 versus 3.7, for a difference of 2.0 [95% Cl 1.27 to 2.82]) and had greater patient satisfaction (8.7 versus 5.7, for a difference of 3.0 [95% Cl 1.82 to 4.29]) than the traditional landmark approach. Conclusion: Ultrasonographic-guided peripheral intravenous access is more successful than traditional "blind" techniques, requires less time, decreases the number of percutaneous punctures, and improves patient satisfaction in the subgroup of patients who have difficult intravenous access.