First-Attempt Success, Longevity, and Complication Rates of Ultrasound-Guided Peripheral Intravenous Catheters in Children :

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. 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. 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 [CI] 39% to 71%). The ultrasonographic group required less overall time (13 minutes versus 30 minutes, for a difference of 17 [95% CI 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% CI 8.2 to 19.4]), and fewer percutaneous punctures (1.7 versus 3.7, for a difference of 2.0 [95% CI 1.27 to 2.82]) and had greater patient satisfaction (8.7 versus 5.7, for a difference of 3.0 [95% CI 1.82 to 4.29]) than the traditional landmark approach. 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.

To develop a clinical prediction rule that would be easy to apply and be useful for predicting success or failure of peripheral intravenous line insertion in children. This was a prospective cohort study of children aged 0 to 21 years undergoing peripheral intravenous placement by staff nurses in a pediatric emergency department. Information on candidate predictor variables was obtained before attempting intravenous placement, and the outcome was successful on first attempt. Backward stepwise logistic regression was used to identify factors independently predictive of success. Those factors remaining in the model were used in a set of linear scores. Receiver operating characteristic curves were constructed for each model, and the areas under the curve were calculated. Six hundred fifteen subjects were enrolled. Success rate for intravenous insertion on first attempt was 75%. A 4-variable proportionally weighted rule (known as the difficult intravenous access [DIVA] score) was created (3 points for prematurity, 3 for younger than 1 year, 1 for 1-2 years of age, 2 for vein not palpable, and 2 for vein not visible). The area under the receiver operating characteristic curve was 0.67. Subjects with a DIVA score of 4 or more were more than 50% likely to have failed intravenous placement on first attempt. A clinical prediction rule that is easy to apply and is useful for predicting success or failure of peripheral intravenous insertion has been created. If externally validated, this DIVA score can be used to predict which children will have difficult intravenous access.

We hypothesized that the use of ultrasound guidance would improve the success rate of peripheral intravenous catheter placement in pediatric patients with difficult access in a pediatric emergency department (ED). Our secondary hypotheses were that ultrasound guidance would reduce the number of attempts, the number of needle redirections, and the overall time to catheter placement.