What are the alternatives to ultrasound-guided peripheral intravenous (IV) placement when it is unsuccessful?

Alternatives to Ultrasound-Guided Peripheral IV Access

When ultrasound-guided peripheral IV access fails, intraosseous access is the recommended alternative in emergency situations, while midline catheters or central venous catheters should be considered for non-emergent cases based on intended duration of therapy and fluid characteristics. 1

Hierarchy of Vascular Access Alternatives

1. Midline Catheters

• 10-20 cm long catheters inserted into upper arm veins
• Appropriate for short to medium-term access (1-4 weeks)
• Particularly useful for antibiotic therapy 1
• Inserted with ultrasound guidance similar to PICC lines
• Tip remains outside central veins
• Cannot be used for infusions requiring central venous administration

2. Intraosseous (IO) Access

• First choice in emergency situations when IV access is difficult
• Faster than central venous access in emergencies 1
• Preferred sites: tibia and humerus
  • Tibial insertion: 2 cm distal to tibial tuberosity, 1 cm medial to tibial plateau
• Can be used for resuscitation fluids and medications
• Success indicators: bone marrow aspiration, saline flush without extravasation, needle supported by bone cortex
• Should be removed within 24 hours once suitable IV access is achieved 1

3. Central Venous Catheters (CVCs)

• Consider when peripheral or midline access is inappropriate
• Indications for CVC over peripheral access:
  • Need for infusion of fluids with high osmolality (>500 mOsm/L)
  • Solutions with pH <5 or >9
  • Vascular access needed for more than 2 weeks 1
  • Administration of vesicants or irritants

CVC Site Selection:

• Subclavian site preferred over jugular or femoral in adults to minimize infection risk 1
• Avoid femoral vein due to increased infection and thrombosis risk 1
• Use ultrasound guidance for CVC placement to reduce complications 1

4. Peripheral Internal Jugular (PIJ) Catheter

• Single-lumen peripheral catheter placed in internal jugular vein
• High success rate (97.1%) even after failed peripheral attempts 2
• Median placement time: 3 minutes
• Low complication rate (2.9% - primarily local hematoma) 2
• Can serve as bridge to avoid central line placement

Alternative Visualization Techniques

When ultrasound is unavailable or unsuccessful:

• Transillumination devices
• Infrared vein visualization devices
• Vein finders 1

Impact of Ultrasound-Guided Peripheral IVs

Studies show that ultrasound-guided peripheral IVs can:

• Prevent 85% of central line placements in patients with difficult access 3
• Reduce central line-associated bloodstream infections 4
• Achieve 99% success rate in patients with difficult access due to edema, obesity, or history of IV drug use 5

Practical Approach to Failed Ultrasound-Guided Peripheral IV

1. Assess urgency and intended therapy duration:

   • Emergency situation → Intraosseous access
   • Non-emergency → Continue to step 2

2. Evaluate therapy characteristics:

   • Duration <6 days → Try alternative peripheral sites or visualization techniques
   • Duration >6 days → Consider midline catheter 1
   • High osmolality, extreme pH, or vesicant medications → Central venous access

3. Consider patient factors:

   • Coagulopathy → Avoid femoral and subclavian approaches
   • Renal failure → Avoid subclavian site to preserve veins for future dialysis access 1
   • Respiratory compromise → Consider femoral approach despite higher infection risk

Complications to Monitor

• Intraosseous: Fracture, extravasation, osteomyelitis, compartment syndrome
• Central venous: Pneumothorax, arterial puncture, infection, thrombosis
• Midline: Phlebitis, infiltration, thrombosis

Remember that all vascular access devices should be removed as soon as they are no longer essential to reduce infection risk 1.

AI: I've provided a comprehensive approach to alternatives when ultrasound-guided peripheral IV access fails, prioritizing patient safety and evidence-based recommendations from current guidelines.