What is the recommended approach for intravenous (IV) placement in patients with a history of difficult venous access, such as the obese, elderly, or those with multiple previous IV placements?

Ultrasound-Guided Peripheral IV Access for Difficult Venous Access

For patients with difficult venous access (obese, elderly, multiple prior IV attempts), ultrasound-guided peripheral IV catheter placement should be used immediately after 2-3 failed traditional attempts, as it increases success rates to 97% compared to 33% with landmark techniques and prevents unnecessary central line placement in 85% of cases. 1, 2, 3

When to Deploy Ultrasound Guidance

• Initiate ultrasound guidance early after standard peripheral IV attempts fail, typically after 2-3 attempts, rather than continuing blind attempts that increase patient discomfort, delay treatment, and raise complication risk 1

• The Association of Anaesthetists of Great Britain and Ireland explicitly advises against continuing repeated blind attempts after initial failures 1

• Ultrasound-guided peripheral IV (USGPIV) placement prevents central venous catheter placement in 85% of difficult access patients, thereby avoiding the higher risks of infection, thrombosis, and pneumothorax associated with central lines 3

Technical Execution Approach

Use real-time two-dimensional ultrasound guidance with a high-frequency linear transducer and sterile technique for all difficult access cases 4

Six-Step Systematic Approach:

1. Identify anatomy and vessel localization using both short-axis (transverse) and long-axis (longitudinal) views before prepping the site 5

2. Confirm vessel patency using compression ultrasound to exclude thrombosis and color Doppler to verify blood flow 5

3. Perform real-time ultrasound-guided puncture using either short-axis/out-of-plane or long-axis/in-plane approach, constantly visualizing the needle tip during advancement 5, 4

4. Confirm needle position centrally in the vein before advancing the catheter 5

5. Advance the needle and catheter device almost entirely into the vessel before threading the catheter to prevent catheter shearing and ensure successful placement 6

6. Confirm final catheter position in both short-axis and long-axis views 5

Choice of Approach: Transverse vs. Longitudinal

• For novice users, use transverse (short-axis) approach or a combination of transverse and longitudinal methods, as these appear most successful in inexperienced hands 7

• Both approaches are acceptable, but the transverse approach allows easier visualization of surrounding structures and reduces risk of posterior wall puncture 4

Duration-Based Device Selection Algorithm

For peripherally compatible infusates:

• ≤5 days: Ultrasound-guided peripheral IV catheter is first-line 5, 8
• 6-14 days: Ultrasound-guided peripheral IV or midline catheter (10-20 cm length in upper arm veins) preferred over PICC 5, 8
• 15-30 days: PICC becomes appropriate 8
• ≥31 days: Tunneled catheters or implanted ports are appropriate 5, 8

For non-peripherally compatible infusates (vesicants, irritants, parenteral nutrition):

• PICC placement is appropriate at any duration, as peripheral devices cannot provide central venous access 5
• Nontunneled CVCs appropriate for ≤14 days if skilled operators available 5

Training and Competency Requirements

Operators must complete systematic training before performing independently, including simulation-based practice, supervised insertions, and evaluation by an expert 4, 1

Minimum competency requirements include:

• Knowledge of target vein anatomy and recognition of anatomical variants 4
• Demonstration of insertion with no technical errors based on procedural checklist 4
• Real-time needle tip tracking with successful cannulation on first attempt in at least five consecutive simulations 4
• Recognition and management of acute complications 4

Success Rates and Clinical Outcomes

• USGPIV placement by trained emergency physicians, nurses, and technicians achieves 97% success rate versus 33% with traditional landmark techniques 2

• No significant difference in success rates between physicians, nurses, and technicians (p=0.13), indicating that all provider types can successfully perform this procedure with proper training 7

• USGPIV reduces time to successful cannulation from 15 minutes to 4 minutes, decreases percutaneous punctures from 3.7 to 1.7 attempts, and improves patient satisfaction scores from 5.7 to 8.7 out of 10 2

Critical Pitfalls to Avoid

• Never use static ultrasound alone to mark the needle insertion site—always use real-time dynamic guidance 4

• Avoid rapid needle movements while "searching for the needle on the ultrasound screen", as this increases risk of arterial puncture, posterior wall penetration, and pneumothorax 5

• Do not proceed with catheter advancement until needle tip is visualized centrally in the target vein, as premature threading causes catheter failure 5, 4

• In patients with stage 3b CKD or greater (eGFR <45 mL/min), avoid placing any devices in arm veins to preserve vessels for future hemodialysis access—use internal jugular tunneled catheters instead 5, 9

Organizational Requirements

• Hospitals must ensure 24/7 availability of personnel skilled in difficult access techniques 1

• Essential resources include high-resolution ultrasound devices with sterile sheaths and gel, dedicated "difficult access" equipment including echogenic needles and needle guides, and local algorithms for complication management 1, 4

• Periodic proficiency assessments of all operators should be conducted to ensure maintenance of competency 4