Difficult IV Access C PG

Clinical Practice Guideline:
Difficult Intravenous Access

In ED patients requiring vascular access, which alternative
techniques improve outcomes compared with traditional
IV insertion
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Table of Contents
Background/Significance_____________________________________________________________________3
Methods___________________________________________________________________________________3
Summary of Literature Review________________________________________________________________5
Description of Decision Options/Interventions and the Levels of Recommendation_______________________11
References________________________________________________________________________________13
Authors__________________________________________________________________________________16
Acknowledgments__________________________________________________________________________16
Appendix 1: Evidence Table__________________________________________________________________17
Appendix 2: Other Resources Table____________________________________________________________35
Appendix 3: Study Selection Flowchart and Inclusion/Exclusion Criteria_______________________________40
2
Background and Significance

Establishing vascular access is one of the most common procedures carried out in the emergency department (ED) and is a high
priority for the care of critically ill and unstable patients. The patient’s condition often plays a role in the likelihood of attaining
vascular access. Difficult intravenous access is defined as requiring multiple attempts and/or the anticipation of needing special
interventions to establish and maintain peripheral venous access (Kuensting, DeBoer, Holleran, Shultz, Steinmann, & Venella,
2009). Conditions associated with difficult vascular access include obesity, chronic illness, hypovolemia, intravenous (IV) drug
abuse, and vasculopathy (Blaivas & Lyon, 2006; Chinnock, Thornton, & Hendey, 2007; Costantino, Parikh, Satz, & Fojtik, 2005;
Doniger, Ishimine, Fox, & Kanegaye, 2009; Heinrichs, Fritze, Vandermeer, Klassen, & Curtis, 2013; Miles, Salcedo, & Spear, 2012;
Nafiu, Burke, Cowan, Tutuo, Maclean, S., & Tremper, 2010; Sebbane et al., 2013). Additionally, age may be a factor in successful
cannulation: in children under the age of two years, particularly young infants, intravenous access is more likely to be difficult to
obtain (Chapman, Sullivan, Pacheco, Draleau, & Becker, 2011; Heinrichs, Fritze, Vandermeer, Klassen, & Curtis 2013) as there is
often a lack of a palpable and visible vein (Nafiu et al., 2010; Yen, Reigert, & Gorelick, 2008).
Decreased time to cannulate and successful vascular cannulation in as few attempts as possible are crucial for the optimal
resuscitation of a critically ill patient. This can be challenging for even the most experienced emergency nurse. Patients with difficult
IV access are frequently subjected to repeated attempts at obtaining IV access by multiple practitioners, which results in frustration
and loss of productivity for the treating team, and delays diagnosis and treatment for patients (Rauch, et al., 2009; Witting, 2012).
In the literature, failure rates of emergent IV access vary from 10–40% (Leidel et al., 2009; Witting, 2012). The number of attempts
at IV cannulation for the pediatric patient ranges from 1 to 10, with the IV nurse clinician having the highest success rate among nurses
and physicians (Katsogridakis, Seshadri, Sullivan, & Waltzman, 2008). The average time needed for peripheral IV cannulation ranges
from 2.5–16 minutes, with difficult IV access requiring as much as 30 minutes (Leidel et al., 2012). Significant delays in care were
reported when IV access required physician intervention, with times to successful cannulation ranging from 22–57 minutes
(Witting, 2012).
Central venous catheterization (CVC) is a common alternative approach to attain cannulation in patients with difficult venous
access. CVC cannulation provides vascular access for fluid resuscitation and can allow for hemodynamic monitoring. Unfortunately,
CVC line placement is associated with well-known risks. Immediate or delayed complications occur in 5–15% of lines (Au, Rotte,
Grzybowski, Ku, & Fields, 2012) and include the interruption of cardiopulmonary resuscitation, venous thrombosis, arterial
puncture, catheter associated bloodstream infection, and pneumothorax (Leidel et al., 2009; Leidel et al., 2012). Given the time
required to establish a central venous catheter, the increased risk to the patient, and the skill required of the provider, other
alternatives for vascular access are often desirable.
Methods
This clinical practice guideline (CPG) was created based on a thorough review and critical analysis of the literature following ENA’s
Clinical Practice Guideline Development Manual (ENA, 2018). All articles relevant to the topic were identified by a comprehensive
literature search of the following databases: MEDLINE, Google Scholar, CINAHL, Cochrane - British Medical Journal, Agency
for Healthcare Research and Quality, and the National Guideline Clearinghouse. Searches were conducted using the search terms
“difficult intravenous access”, “tools intravenous access”, “heat”, “nitroglycerin”, “tourniquet”, “ultrasound”, “light”, “illumination”,
“subcutaneous rehydration therapy”, and “hypodermoclysis”, using a variety of different search combinations. Searches were limited
to English language articles on human subjects from January 2003–October 2015. A 2018 update on this CPG searched for articles
published from 2015–2018 and included the additional keywords “interosseous”, “infrared”, and “ultrasound guided”. In addition, the
references of the selected articles were scanned for pertinent research findings. Meta-analyses, systematic reviews, and research articles
from emergency department settings, non-ED settings, position statements, and guidelines from other sources were reviewed (Appendix 3).
Clinical findings and levels of recommendation regarding patient management were made by the CPG Committee according to ENA’s
classification of levels of recommendation for practice (Table 1). The articles reviewed to formulate the recommendations in this CPG
are described in Appendix 1.
3
Table 1. Levels of Recommendation for Practice

Level A Recommendations: High
• Reflects a high degree of clinical certainty

• Based on availability of high-quality level I, II and/or III evidence available using Melnyk & Fineout-Overholt grading system
(Melnyk & Fineout-Overholt, 2019)
• Based on consistent and good quality evidence; has relevance and applicability to emergency nursing practice
• Is beneficial
Level B Recommendations: Moderate
• Reflects moderate clinical certainty

• Based on availability of Level III and/or Level IV and V evidence using Melnyk & Fineout-Overholt grading system
(Melnyk & Fineout-Overholt, 2019)
• There are some minor or inconsistencies in quality evidence; has relevance and applicability to emergency nursing practice
• Is likely to be beneficial
Level C Recommendations: Weak
• Level V, VI and/or VII evidence available using Melnyk & Fineout-Overholt grading system (Melnyk & Fineout-Overholt,
2019)
• Based on consensus, usual practice, evidence, case series for studies of treatment or screening, anecdotal evidence
and/or opinion
• There is limited or low-quality patient-oriented evidence; has relevance and applicability to emergency nursing practice
• Has limited or unknown effectiveness
Not Recommended for Practice
• No objective evidence or only anecdotal evidence available, or the supportive evidence is from poorly controlled
or uncontrolled studies
• Other indications for not recommending evidence for practice may include:
◦◦ Conflicting evidence
◦◦ Harmfulness has been demonstrated
◦◦ Cost or burden necessary for intervention exceeds anticipated benefit
◦◦ Does not have relevance or applicability to emergency nursing practice
• There are certain circumstances in which the recommendations stemming from a body of evidence should not be rated
as highly as the individual studies on which they are based. For example:
◦◦ Heterogeneity of results
◦◦ Uncertainty about effect magnitude and consequences
◦◦ Strength of prior beliefs
◦◦ Publication bias
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Summary of Literature Review

This review is organized into adult and pediatric sections for ease of information retrieval. The first section will focus on adults
and discuss ultrasound-guided IV cannulation, intraosseous (IO) access, subcutaneous rehydration therapy (SCRT), warming, and
other alternatives for use in IV cannulation. A section on IV cannulation in pediatrics will follow and discuss ultrasound-guided IV
cannulation, IO access, SCRT, EMLA Cream™ and vapocoolants, and alternative methods of vein
finding.
DIFFICULT INTRAVENOUS ACCESS IN ADULTS

Ultrasound-Guided Intravenous Access
The use of ultrasound to guide IV cannulation in patients with difficult IV access has been widely studied in adults in the ED setting.
Ultrasound guidance provides a real-time 2-D image of blood vessels, which appear as compressible circular structures (Walker, 2009;
Troianos et al., 2012). The technique has been used successfully by nurses, physicians, and ED technicians to start peripheral IVs in
patients with difficult venous access (Brannam, Blaivas, Lyon, & Flake, 2004; Bauman, Braude, & Crandall, 2009; Schoenfeld, Boniface,
& Shokoohi, 2011; Scoppettuolo et al., 2016). Several parameters have been studied in relation to ultrasound use and standard IV
cannulation techniques of visualization and palpation, including: success rate, first attempt success rate, number of attempts, time to
cannulation, and patient satisfaction.
Successful Cannulation with Ultrasound Guidance

Evidence regarding the use of ultrasound for peripheral intravenous cannulation in adult patients with difficult IV access is not
universally supportive of its efficacy in practice when compared with the standard IV cannulation techniques of palpation and
visualization (Bahl, Pandurangadu, Tucker, & Bagan, 2016; Costantino, Kirtz, & Satz, 2010; Costantino, Parikh, Satz, & Fojtik,
2004; Scoppettuolo et al., 2016; Stolz, Stolz, Howe, Farrell, & Adhikari, 2015). In a randomized controlled trial of 122 adults, Bahl
et al. (2016) found that ultrasound-guided IV insertion by nurses was more successful than standard techniques (76% vs. 56%) (OR
2.52, p = 0.02). Further, in a systematic review and metanalysis (N = 6), Stolz et al. (2015) found that ultrasound-guided IV insertion
was more frequently successful than traditional methods (OR 3.96, 95% CI [1.75,8.94]). However, McCarthy et al. (2016) found that
while ultrasound-guided IV insertion by ED technicians was more successful than standard techniques in patients with difficult IV
access (48 more successes per 100 attempts, 95% CI [35.6,60.3]), the use of standard techniques was more successful than ultrasound
in patients with easy IV access (10.6 more successes per 100 attempts, 95% CI [5.8,15.4]). Lastly, three studies found there was no
difference in successful cannulation rates between ultrasound and standard techniques (Aponte et al., 2007; Bauman et al., 2009; Liu,
Alsaawi, & Bjornsson, 2014).
While there is evidence that ultrasound may be more successful for cannulation than standard techniques in patients with difficult
IV access, the data are not overwhelmingly in support of this technique. This information is helpful in that it suggests that the use of
ultrasound for IV cannulation in patients with difficult IV access is equally as successful as using standard techniques of palpation
and visualization. The different study designs, inconsistent definitions of difficult IV access, and differing operators among studies
make it difficult to draw conclusions about the utility of ultrasound in increasing IV cannulation success compared with palpation
and visualization.
Time to Cannulation
Several studies sought to compare the time to successful cannulation using ultrasound guidance vs. standard techniques, and the
findings among these studies vary. Two studies found that the times to successful cannulation using ultrasound guidance differed
from those using standard techniques. Bauman et al. (2009) found that ultrasound-guided IV placement by ED technicians was two-
times faster than standard techniques (95% CI [1.3,3.1]), and Costantino et al. (2005) found that ultrasound-guided IV placement by
nurses was 17 minutes faster (95% CI [0.8,25.6]) than standard techniques. Conversely, data from multiple studies indicate that there
is no difference in time to successfully start an IV whether using ultrasound or standard techniques (Aponte et al., 2007; Bahl et al.,
2016; Stein, George, River, Hebig, & McDermott, 2009; Stolz et al., 2015; Weiner et al., 2013). In a randomized controlled trial, Bahl
et al. (2016) found no significant difference (p = 0.75) in the time needed to start an IV using ultrasound (15.8 min) vs. standard techniques
(20.7 minutes). Further, in a meta-analysis, Stolz et al. (2015) found that ultrasound guidance did not have an effect on time to success-
5
fully cannulate when compared with standard techniques (ultrasound = −1.07 min, 95% CI [−4.66,2.52]). Based on this evidence, we
can infer it may take the same amount of time to use ultrasound to successfully start an IV as it does using standard techniques. The
information is limited, however, and does not allow for clinical recommendations on this topic.
Patient Satisfaction and Pain

Patient satisfaction and pain have been assessed in studies comparing ultrasound-guided IV insertion with standard techniques, and
the results have differed. Costantino et al. (2005) found that satisfaction in patients with difficult IV access (N = 60) was significantly
higher in the ultrasound group (8.7 ± 1.6) than in the standard-procedure group (5.7 ± 3.2) (95% CI [1.82,4.29]). Similarly, Bauman et
al. (2009) found that patients in the ultrasound group had significantly higher satisfaction (79) than the standard technique group (44)
(p < 0.0001). Conversely, three studies found no difference in patient satisfaction or pain related to IV insertion technique (McCarthy
et al., 2016; Stein et al., 2009; Weiner et al., 2013). For instance, McCarthy et al. (2016) found pain in the ultrasound group was
higher than in the standard technique group regardless of the level of difficulty, although the differences were not significant. While
this is a worthwhile variable to investigate in relation to difficult IV access, there is limited evidence available with which to draw
conclusions regarding the effect that ultrasound guidance has on pain and patient satisfaction when starting IVs in patients with
difficult IV access.
Conclusions
Routine use of ultrasound-guided peripheral venous cannulation is not recommended (Liu et al., 2014; Troianos et al., 2012).
However, ultrasound guidance should be considered in patients with known difficult peripheral venous access, especially when
traditional techniques have failed (Egan et al., 2013; Heinrichs et al., 2013; Liu et al., 2014; Stolz et al., 2015).
Intraosseous Vascular Access

Intraosseous (IO) vascular access dates back as far as the 1920s when the sternum was described as a potential site for transfusions
(Fowler et al., 2007; Horton & Beamer, 2008; MacKinnon, 2009; Paxton, Knuth, & Klausner, 2009; Weiser, Hoffman, Galbraith &
Shavit, 2012). The IO route was later used by military medical personnel during WWII when vascular access was needed for patients
in shock, and IV cannulation was difficult or delayed (Fowler et al., 2007). Subsequently, the availability of plastic catheters for
peripheral and central IV access resulted in a decline in IO usage that continues today despite strong evidence supporting IO access
and recommendations from numerous reputable medical organizations (Voigt, Waltzman, & Lottenberg, 2012).
There are three different types of IO needle placement methods. First, the manual needle is hollow with a removable stylet. The
second is the impact-driven device, of which there are two types: one is designed for sternal access, the other has a spring-loaded
injector mechanism designed for the tibia. The third type is a battery-powered, drill-based technology. There are three lengths of IO
needles available for the drill device to accommodate pediatric, adult, and obese patients (Leidel et al., 2009). The recent introduction
of these various IO insertion devices has made the IO route an option for vascular access in the adult population (Langley & Moran,
2008; MacKinnon, 2009; Voigt et al., 2012; Von Hoff, Kuhn, Burris, & Miller, 2008; Phillips et al., 2010).
Intraosseous access is an alternative to IV access. The IO route is effective for the administration of blood and blood products, fluid
administration, drug delivery, and blood sampling (Burgert, 2009; Leidel et al., 2009; Paxton et al., 2009; Petitpas et al., 2016). It is
recommended for use when vascular access is problematic (Garside, Prescott, & Shaw, 2016) and could delay patient care, and when
an increase in patient morbidity or mortality is possible (Phillips et al., 2010). Further, for patients not requiring long-term vascular
access or hemodynamic monitoring, IO access should be the first alternative to failed peripheral venous access (Phillips et al., 2010).
While IO access is recommended in these situations, research indicates that, in the context of non-traumatic out-of-hospital cardiac
arrest, IO use is associated with lower survival rates and poor neurologic recovery (Kawano et al., 2018).
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Success Rate on First Attempt

Several studies investigated the success of initiating IO access on the first attempt. Horton and Beamer (2008) found a 93% first-time
success rate but did not discuss the specific parameters defining success. Leidel et al. (2009) attained 90% first-time success; success
was defined as successful administration of drugs or infusion solutions on first effort. The success rate of the IO access on first
attempt was reported by Paxton et al. (2009) as 80.6% in the proximal humerus. No determining factors for success were identified
in this study. Leidel et al. (2012) conducted a study to evaluate first-time success rates comparing IO access to CVC placement in
patients requiring medical or trauma resuscitation and found that the success rate for IO placement was 85% compared with a CVC
line first-attempt placement success rate of 60% (χ2 = 5.078, df = 1, p = 0.024). Success was defined as successful administration of
fluids or medications via the newly established IO or CVC (Leidel et al., 2012). Research indicates that there is a high success rate of
IO insertion on the first attempt, making it a viable alternative to IV access.
Time to Insertion
Several researchers found that intraosseous access can be accomplished quickly and efficiently. Horton and Beamer (2008) reported
an insertion time of less than 10 seconds in 80.2% of subjects. Time was measured from the time of needle-to-skin contact to
needle placement in the IO space. Leidel et al. (2009) reported an insertion time of 2.3 ± 0.8 minutes. In this study, an independent
researcher measured the time from picking up the IO access device through preparing the set, prepping the site and inserting the
IO needle, to the administration of the first drug or fluid. Paxton et al. (2009) reported a time of 1.5 minutes for IO insertion in the
proximal humerus. Timing began with the skin preparation before insertion and ended when the person completing the insertion
deemed the flow of the fluid was adequate. Leidel et al. (2012) found a significant difference in time to insertion when comparing IO
access with CVC line placement, with IO placement being six minutes faster (p < 0.001, 95% CI [5.0,7.0]). IO insertion can be done
quickly, making it an excellent option when vascular access is needed urgently.
Patient Report of Pain on Insertion and Infusion

Several studies reported findings about patient pain on IO insertion and infusion. Paxton et al. (2009) assessed pain scores using a
visual analogue scale (VAS) on insertion of the IO access device into the proximal humerus in adult patients with a Glasgow Coma
Scale (GCS) score of 15 and reported an average pain score of 4.5. They also assessed pain scores utilizing a VAS on infusion of
fluids through the IO port and reported an average score of 3.8 following lidocaine administration. All patients were given a dose of
40 to 100 mg of lidocaine 2% through the IO needle prior to infusion of fluids or medications. Horton and Beamer (2008), without
mention of administration of lidocaine, reported a mean pain score of 3.2 ± 3.5 on infusion of fluids through the IO in patients with a
GCS greater than eight.
Conclusions
The evidence indicates that IO access is an effective alternative to intravascular access. IO access can be accomplished in a timely
manner with little discomfort and provides vascular access for medications, infusions, and lab draws. IO access is still significantly
underutilized in emergency care and should be considered when rapid vascular access is needed and the patient presents with
difficult peripheral venous access. Further study is needed regarding the association of IO access with patient morbidity and
mortality.
Subcutaneous Rehydration Therapy

Also known as hypodermoclysis, subcutaneous rehydration therapy (SCRT) dates back to 1913 (Spandorfer, 2011) as an alternative
method for rehydration in mild to moderate dehydration when oral or IV hydration is not feasible. The physiology behind SCRT
stems from the sodium–potassium pump providing an osmotic gradient. The subcutaneous tissue forms a thick matrix with
hyaluronic acid (Allen et al., 2009, Kuensting, 2011; Spandorfer, 2011). A recent innovation in SCRT involves the administration of
hyaluronidase, which modifies the permeability of connective tissue, decreasing the viscosity of the cellular cement and promoting
absorption of injected fluids. By injecting hyaluronidase into the subcutaneous tissue, the permeability of the matrix is increased
and allows space for the infusion of fluid. The site selected for infiltration should be an area where the skin and subcutaneous
tissue can be pinched, such as the thighs, abdomen, or arms (Remington & Hultman, 2007). Fluid may be infused by gravity or by
pump at a rate of 20 to 125 mL/h over a 24-hour period. Absorption of fluid is dependent on the osmotic gradient, not on the rate of
administration (Kuensting, 2011).
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Several studies have been conducted on the use of subcutaneous rehydration therapy in adults. Remington and Hultman (2007)
reviewed literature on SCRT and identified eight studies. When comparing SCRT with IV administration from a safety perspective,
the two were found to be comparable. It was noted, however, that subjects in these studies were elderly, with mean ages ranging
from 71 to85 years. The incidence of systemic adverse effects did not differ (Remington & Hultman, 2007). Further, they
demonstrated that more subjects improved clinically with IV administration than with SCRT, but the difference was not statistically
significant (81% IV, 57% SCRT, p = 0.19). Site changes were necessary on an average of every 2 days with SCRT and 2.8 days for
IV administration (p = 0.14) (Remington & Hultman, 2007; Slesak, Schnürle, Kinzel, Jakob, & Dietz, 2003). Median duration of
fluid administration was six days for both SCRT and IV routes (Slesak et al., 2003). Nurses rated the feasibility of SCRT equal to
that of an IV catheter (Remington & Hultman, 2007; Slesak et al., 2003). Nursing time to initiate SCRT was significantly lower at
3.4 minutes versus 6.1 minutes for initiation of an IV catheter. A significant difference was seen in the median volume of solution
administered, with 750 mL/day for SCRT and 1000 mL/day for IV administration (p = 0.002) (Slesak et al., 2003). A systematic
review by Forbat, Kunicki, Chapman, and Lovell (2017) found a paucity of evidence regarding the site, volume, and rate of SCRT,
leaving little to guide clinicians in their use of this method of fluid administration. SCRT may be an effective intervention for
rehydration of mild to moderately dehydrated adult patients in the emergency setting. However, there is little evidence in the current
literature to guide the use of this method of fluid administration.
Warming
The use of heat to facilitate vasodilatation for IV insertion is widely practiced. Caution must be used with this technique as tissue
damage may occur if not closely monitored and controlled. The U.S. Food and Drug Administration (FDA) issued a patient safety
warning in 2002 against using forced air warmers without the blanket — a practice known as “hosing” — because second- and third-
degree burns have resulted (FDA, 2002).
Studies specific to the ED setting are limited. Lenhardt, Seybold, Kimberger, Stoiser, and Sessler (2002) used a specific device on
adult patients on neurosurgery and hematology units to conduct a randomized controlled study with a crossover trial of warming to
facilitate IV cannulation. The study compared passive warming with active warming and found that, after 15 minutes of warming,
the success rate for IV cannulation was 94% (44/50) in the active warming group compared with 72% (36/50) in the passive warming
group (p = 0.008). Additionally, cannulation required less time with active warming: 36 seconds compared with 62 seconds for
passive warming. The crossover trial applied warming for 10 minutes and found a 95% success rate for the active warming group
compared with 73% for the passive warming group (p = 0.001). The time required for successful cannulation was 20 seconds shorter
for active compared with passive warming (p = 0.02) (Lenhardt et al., 2002).
Fink et al. (2009) conducted a randomized controlled study to compare dry heat with moist heat. Dry heat was 2.7 times more
likely to result in successful IV insertion on first attempt (p = 0.039). The difference in mean insertion time between dry heat (98.5
seconds) and moist heat (127.6 seconds) was large enough to be clinically meaningful. No significant difference in patient anxiety
was found between the heat modalities or between nurse- or post-insertion patient-reported anxiety scores (p > 0.54). The conclusion
recommended dry heat because of low cost, safety to patients, and feasibility (Fink et al., 2009).
In summary, controlled warming to facilitate IV cannulation is a therapeutic option that can be used to improve cannulation success
rate in a timely manner. It is low cost and convenient for clinicians and patients.
DIFFICULT INTRAVENOUS ACCESS IN PEDIATRICS

Ultrasound-Guided Intravenous Access
Ultrasound guidance for IV cannulation has been studied in the pediatric population. As in adults, several parameters have been
studied in relation to ultrasound use and standard IV cannulation techniques of visualization and palpation, including success rate,
first attempt success rate, number of attempts, and time to cannulation
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Successful Cannulation with Ultrasound Guidance

Ultrasound guidance has been used in the pediatric population to start IVs with varying success (Avelar, Peterlini, & Pedreira, 2015;
Benkhadra et al., 2012; Heinrichs et al., 2013). Three studies found that the use of ultrasound to guide IV cannulation increased
successful IV starts. A systematic review and meta-analysis that included three RCTs, two of which were done in an emergency
setting, found that ultrasound-guided peripheral IV cannulation significantly reduced the number of cannulation attempts in
pediatric patients (Heinrichs et al., 2013). Another study found the first attempt success for ultrasound-guided methods was 35%
compared with 29% for traditional methods. The crossover group in this study that had failed by the traditional method had a 75%
first-attempt success rate with ultrasound-guided methods (Bair, Rose, Vance, Andrada-Brown, & Kuppermann, 2008). Lastly, a
small randomized controlled trial found that ultrasound guidance significantly increased first-attempt success when compared with
traditional methods (85% vs. 35%, p = 0.0012). Conversely, two studies found that the use of ultrasound guidance to start IVs did
not significantly increase success rates. A randomized controlled trial by Doniger et al. (2009) did not demonstrate a significant
difference in overall success rates of IV cannulation with ultrasound-guided technique compared with traditional technique (80%
and 64%; p = 0.208). However, the ultrasound group had statistically significant improvements in the number of attempts (p = 0.004)
and number of needle redirections (p < 0.0001) compared with the control group (Doniger et al., 2009). Avelar et al. (2015) found no
significant difference in vascular access success between the control group utilizing standard vascular access techniques (91.8%) and
the US-guided access group (85.6%). While it appears that ultrasound-guided IV cannulation may improve successful start rates, the
evidence is not conclusive regarding the benefits of this technique.
Time to Cannulation
In the pediatric population, the time to successful cannulation may be decreased with the use of ultrasound guidance. Two studies
found that the use of ultrasound guidance to start IVs significantly decreased the time to successful cannulation. Median time to
cannulation in the study by Benkhadra et al. (2012) was 63.5 seconds in the ultrasound group compared with 420.5 seconds for the
control group (p < 0.001). In a study by Doniger et al. (2009), the ultrasound-guided IV group required significantly less time to
successfully start an IV compared with the control group (p = 0.001). Ultrasound guidance may allow for quicker IV cannulation,
but the evidence is limited, making it difficult to make recommendations regarding its use.
Intraosseous Access
Intraosseous access has been the standard of care for over 20 years for the pediatric population when vascular access is difficult to
accomplish (Horton & Beamer, 2008). There is therefore little new evidence to review regarding IO access in pediatrics. Findings
from previous CPGs indicate that there is little pain experienced when the IO is inserted (Horton & Beamer, 2008). Current data
focus on the success rate of a manual or drill-assisted IO insertion device. A retrospective descriptive study found that the EZ-IO®
was less successful in starting IO access in children under eight kilograms, and that manual IO insertion was successful in children
both less than and more than eight kilograms. Further, manual IO access was quicker than the EZ-IO® in those less than eight
kilograms (4.5 min vs. 12.8 min, p = 0.02) (Pifko et al., 2018). The IO remains the standard of care in the pediatric population when
vascular access is difficult, but there is little evidence to guide suggestions on which type of insertion device is the most successful in
this population.
Subcutaneous Rehydration Therapy

Subcutaneous rehydration therapy in the pediatric population has been extensively investigated, but at the time of writing there
have been no recent studies. First-line treatment for pediatric patients with mild to moderate dehydration is with an oral rehydration
solution (Wolf & Delao, 2015). However, should SCRT be needed, the preferred site in children is between the scapula (Kuensting,
2011). A study by Allen et al. (2009) investigated recombinant human hyaluronidase-enabled subcutaneous (rHRSC) therapy
in children aged 2 months to 10 years (N = 51) to analyze rehydration and possible adverse events. First-time placement of the
subcutaneous catheter was achieved in 90.2% of attempts (46/51), with successful rehydration for 84.3% of patients (43/81). There
was one case of cellulitis at the site. The nurses who completed the procedure considered it easy to perform for 96% of patients
(46/51), with 90% of the parents (43/48) rating themselves “satisfied” to ”very satisfied” with the procedure (Allen et al., 2009).
Spandorfer et al. (2012) conducted a randomized controlled clinical trial to evaluate whether rHFSC fluid administration can be
safely and effectively administered with volumes similar to IV infusions in mildly to moderately dehydrated children. Children aged
one month to 10 years were randomized to receive 20 mL/kg of isotonic fluids using rHFSC or IV infusion over one hour and then
9
until clinically rehydrated (including the inpatient phase of care for admitted children). The primary outcome was mean total volume
infused. This showed that more fluid was administered intravenously than subcutaneously when including ED and inpatient phases
of care: 31.2 (24.17) mL/kg via the rHFSC route (n = 73) delivered over 3.1 hours (mean) versus 35.8 (52.43) mL/kg delivered via IV
(N = 75) over 6.6 hours (p = 0.51). However, when evaluating only the ED volumes infused, the subcutaneous route was shown to
be superior: 28.7 (16.52) mL/kg rHFSC vs. 22.2 (16.68) mL/kg IV, p = 0.03). Spandorfer et al. (2012) concluded that subcutaneous
hydration facilitated by rHFSC is a reasonable treatment option in the emergency setting for pediatric patients who are mildly to
moderately dehydrated, especially for children with difficult IV access. This finding was supported by a retrospective descriptive
study conducted by Kuensting (2013) that explored whether administration of subcutaneous fluids enhanced the success of venous
cannulation. Kuensting (2013) compared children who received SCRT prior to IV attempts with children who received SCRT after
failed IV attempts and found that the SCRT group experienced a significantly decreased time to fluid infusion (21 minutes) compared
with the IV/SCRT group (97 minutes). The SCRT group also had fewer needle sticks (median = 1) than the IV/SCRT group (median
= 5). Preliminary evidence indicated that initial SCRT may improve IV access in mildly to moderately ill children in the emergency
setting; however, larger scale RCT studies are needed to validate these findings. For further guidance on the treatment of pediatric
dehydration, please see the Emergency Nurses Association, Translation into Practice (TIP) guidance for Pediatric Oral Rehydration
(Wolf & Delao, 2015).
EMLA CreamTM and Vapocoolants

The use of EMLA Cream™ and vapocoolants to decrease pain for pediatric patients is common practice; however, the utility of
these medications is not certain. The use of EMLA Cream™ may result in constriction of the vein. Huff et al. (2009) evaluated
the effect of heat with EMLA Cream™ to facilitate IV cannulation. Ultrasound technology was used to measure vein size prior
to EMLA Cream™ application, one hour after application of EMLA Cream™, and 2 minutes after heat application. The changes
in vein measurement over time were statistically significant (F = 2.58, p < 0.001), indicating approximately 51% variance in vein
measurement attributable to EMLA Cream™ and/or heat when other conditions are stable. The average vein measurements were
0.243 cm at baseline, 0.205 cm after EMLA Cream™, and 0.253 with heat. The difference in vein visualization was also statistically
significant (F = 2.58, p < 0.001). The study had an 80% first-cannulation success rate (Huff et al., 2009). In 2018, Schreiber et al.
found no significant difference in IV cannulation success between the control (89%) and the study group (88%) in which heat and
EMLA were used (p = 0.081).
A meta-analysis of eight studies on the use of vapocoolant found that pain levels were decreased in those who received vapocoolant
and that it would not likely increase the difficulty of IV insertion (Griffith, Jordan, Herd, Reed, & Dalziel, 2016). This meta-analysis
included adult studies making it difficult to identify how this substance specifically affected the pediatric population.
Alternative Devices
Noting the frustration experienced by healthcare professionals when faced with establishing IV access in the ED, several groups
have devoted time to developing devices to assist with IV access. Near-infrared light illuminates the skin without ionizing radiation
and produces a 2-D image of blood-filled structures (Perry, Caviness, & Hsu, 2011; Rothbart et al., 2015). The literature reviewed
for these devices was limited to pediatric populations because there was none found pertaining to adults. Perry et al. (2011) found
the nursing staff (N = 14) felt the device was beneficial for 90% of patients who had difficult IV access. While 70% of the nurses
surveyed found the device helpful for dehydrated patients and 80% found it helpful in the chronically ill population, there was
no significant difference in the first attempt success rate between standard IV techniques (n = 62, 79%) and the infrared device
(n = 61, 72.1%) (Perry et al., 2011). The VeinViewer®, a near-infrared technology device, was studied with a population of pediatric
emergency patients aged 0-17 years, with the finding that there was no statistically significant difference in time to IV placement
or first-time success rates between the groups (78% in the standard technique group and 79% in the VV group; χ2 = 0.39, p = 0.53)
(Chapman et al., 2011). Similarly, Curtis et al. (2015) found that the VeinViewer® did not significantly improve the first attempt rate
or the number of IV attempts compared with ultrasound or standard IV-start techniques. McNeely, Reem, Thrasher, Dziadkowiec,
& Callahan (2018) also studied the VeinViewer® and found there was no significant difference in the number of successful IV starts
or time to IV start between the VeinViewer® group and the traditional methods IV start group. Rothbart et al. (2015) found no
significant reduction in vascular access initiation time or the number of attempts using the ACCUVEIN™, another infrared device.
Szmuk et al. (2013) also conducted a study comparing traditional IV access techniques to IV access with VeinViewer ® assistance
10
in patients aged 0–18 years. This study was terminated early based on the harm threshold being crossed for the primary outcome
measure (first attempt insertion success) (Szmuk et al., 2013). Preliminary findings indicated that use of the near-infrared device
worsened first-time success rates when used by experienced pediatric nurses (Szmuk et al., 2013).
Transillumination of veins using fiber optics in pediatric patients is another method studied (Katsogridakis et al., 2008).
Transillumination did not improve first attempt success (p = 0.53), rather, use of a safety catheter (p = 0.01) and vein visibility
(p = 0.01) and palpability (p = 0.02) were better predictors of first attempt success (Katsogridakis et al., 2008).
Based on the evidence reviewed, these devices do not significantly improve IV cannulation success or time to cannulation.
We conclude that these devices have not been demonstrated to be beneficial for the care of pediatric patients in the emergency
department.
Description of Decision Options/Interventions and the Level of Recommendation

Conclusions and recommendations about alternatives to venous access in the patient with difficult IV access in the ED:
Adults
Ultrasound-guided access should be considered for adult patients with difficult access who have had unsuccessful peripheral IV
attempts using traditional methods. (Bahl et al., 2016; Egan et al., 2013; Heinrichs et al., 2013; Liu et al., 2014; McCarthy et al., 2016; A
Scoppettuolo et al., 2016; Stolz et al., 2015)
Ultrasound- Ultrasound-guided IV access is a technique that can effectively be performed by physicians, nurses, and ED technicians. (Bahl et al.,
Guided 2016; Bauman et al., 2009; Blaivas & Lyon, 2006; Brannam et al., 2004; Chinnock et al., 2007; Costantino et al., 2005; Panebianco et A
Intravenous al., 2009; Schoenfeld et al., 2011; Scoppettuolo et al., 2016; Stein et al., 2009; Weiner et al., 2013)
Access
Ultrasound-guided IV insertion may not decrease patients’ pain level on insertion. (McCarthy et al., 2016; Stein et al., 2009; Weiner
B
et al., 2013)
Ultrasound-guided techniques may result in improved patient satisfaction. (Bauman et al., 2009; Costantino et al., 2005) C
Intraosseous (IO) access is an alternative to IV access and is effective for the administration of blood and blood products,
fluid administration, drug delivery, and blood sampling. (Burgert, 2009; Leidel et al., 2012; Leidel et al., 2009; Paxton et al., 2009; A
Intraosseous Petitpas et al., 2016; Phillips et al., 2010)
Vascular
Access In alert patients, pain with IO needle insertion is rated as minor. (Paxton et al., 2009) C
IO lidocaine administration prior to medication infusion reduces the pain felt by alert patients. (Paxton et al., 2009) C
Subcutaneous
SCRT is an alternative to peripheral IV insertion for mildly to moderately dehydrated older adult patients when oral rehydration
Rehydration B
efforts have been unsuccessful. (Forbat et al., 2017; Remington & Hultman, 2007; Slesak, et al., 2003)
Therapy
Controlled warming to facilitate IV cannulation is a therapeutic option that can be used to improve cannulation success rate
Warming C
in a timely manner. (Fink et al., 2009; Lenhardt et al., 2002)
11
Pediatrics
Ultrasound-
Guided There is insufficient evidence to make recommendations regarding the benefits of ultrasound-guided IV insertion in the
I/E
Intravenous pediatric population.
Access
Intraosseous
There is insufficient evidence to make recommendations regarding which IO insertion device is the most successful in the
Vascular I/E
pediatric population.
Access
Subcutaneous
SCRT is an alternative to peripheral IV insertion for the mildly to moderately dehydrated pediatric patient when oral rehydration
Rehydration C
efforts have been unsuccessful. (Allen, et al., 2009; Kuensting, 2013; Spandorfer et al., 2012)
Therapy
EMLA and The use of EMLA or vapocoolants may increase the success rate for IV access in pediatric patients. (Huff et al., 2009; Schreiber et
C
Vapocoolants al., 2018)
The use of alternative devices does not improve the IV start success rate or time to cannulation in pediatric patients. (Chapman et al.,
Alternative
2011; Curtis et al., 2015; Katsogridakis et al., 2008; McNeeley et al., 2018; Perry et al., 2011; Rothbart et al., 2015; Simhi, Kachko, A
Devices
Bruckheimer, & Katz, 2008; Szmuk et al., 2013)
Level A (High) Based on consistent and good quality of evidence; has relevance and applicability to emergency nursing practice.
Level B (Moderate): There are some minor inconsistencies in quality evidence; has relevance and applicability to emergency nursing practice.
Level C (Weak) There is limited or low-quality patient-oriented evidence; has relevance and applicability to emergency nursing practice.
N/R Not Recommended Based upon current evidence.
I/E: Insufficient evidence upon which to make a recommendation.
N/E: No evidence upon which to make a recommendation.
12
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Weiser, G., Hoffmann, Y., Galbraith, R., & Shavit, I. (2012). Current advances in intraosseous infusion - a systematic review. Resuscitation, 83(1), 20–26.
doi:10.1016/j.resuscitation.2011.07.020
Witting, M. D. (2012). IV access difficulty: Incidence and delays in an urban emergency department. Journal of Emergency Medicine, 42(4), 483–487. doi:10.1016/j.
Wolf, L., & Delao, A. M. (2015). Translation into practice: Pediatric oral rehydration for gastroenteritis. Des Plaines, IL: Emergency Nurses Association.
Retrieved from https://www.ena.org/docs/default-source/resource-library/practice-resources/tips/pediatric-oral-rehydration-for-gastroenteritis.
pdf?sfvrsn=e73c9340_8
Yen, K., Riegert, A., & Gorelick, M. H. (2008). Derivation of the DIVA score: A clinical prediction rule for the identification of children with difficult intravenous
access. Pediatric Emergency Care, 24(3), 143–147. doi:10.1097/PEC.0b013e3181666f32
15
Authors
2018 ENA Clinical Practice Guideline Committee
Annie Horigan PhD, RN
Mary Alice VanHoy MSN, RN, CEN
Janet Kaiser DNP, RN
Judith Young Bradford PhD, RN
Stephen Stapleton PhD, RN
Jean Proehl MSN, RN
Robin MacPherson-Dias
Andi Slivinski DNP, RN
Andi Foley DNP, RN
Susan Barnason PhD, RN
ENA 2018 Board of Directors Liaison: Gordon Gillespie, PhD, RN

Methodologist: Jessica Bishop-Royse, PhD, MS
Staff Liaison: Altair Delao, MPH, Senior Associate
Administrative Staff: Leslie Gates, Senior Administrative Assistant
Acknowledgments
ENA would like to acknowledge the following member of the 2019 Institute for Emergency Nursing Research (IENR) Advisory
Council for her review of this document:
Kathy Baker, PhD, RN, NE-BC
Paul R. Clark, PhD, MA, RN
Courtney Edwards, DNP, MPH, RN, CEN, CCRN, TCRN
Kimberly Johnson, PhD, RN, CEN
Kathleen E. Zavotsky, PhD, RN, CEN, ACNS-BC, CCRN, FAEN
Developed: December 2011

Revised: October 2018
© Emergency Nurses Association, 2019
ENA’s Clinical Practice Guidelines (CPGs), including the information and recommendations set forth herein (i) reflect ENA’s current position with respect to the
subject matter discussed therein based on current knowledge at the time of publication; (ii) are only current as of the publication date; (iii) are subject to change without
notice as new information and advances emerge; and (iv) do not necessarily represent each individual member’s personal opinion. The positions, information, and
recommendations discussed herein are not codified into law or regulations. Variations in practice and a practitioner’s best nursing judgment may warrant an approach
that differs from the recommendations herein. ENA does not approve or endorse any specific sources of information referenced. ENA assumes no liability for any injury
and/or damage to persons or property arising from the use of the information in this Clinical Practice Guideline.
16
Appendix 1: Evidence Table
Research/Purpose Quality of Level of

Reference Design/Sample Setting Variables/Measures Analysis Findings/Implications
Questions/Hypothesis Evidence Evidence
Allen, C. H., Etzwiler, L. To assess efficacy, safety, and Design: Multicenter single-arm Measures: The efficacy primary Findings: Efficacy: 48/51 (94.1%) 2 VI
S., Miller, M. K., Maher, G., clinical utility of recombinant- pilot study. IRB approved for endpoint was adequate rehydration patients received hydration through
Mace, S., Hostetler, M. A., . . . human-hyaluronidase-facilitated each site. Sample: N = 51 children from the ED without requiring SCRT; 43/51 (84.3%) were treated
Harb, G. (2009). Recombinant rehydration in children 2 months to between ages 2 months and 10 alternative treatment modalities. within the ED stay; 5/51 (9.8%)
human hydraluronidase-enabled 10 years old. years, weighing less than 42 kg, Secondary efficacy was change required hospitalization for
subcutaneuos pediatric rehydration. with symptoms of dehydration and in hydration symptoms. Ease of rehydration. 3/51 (5.9%) required
Pediatrics, 124(5), e858–867. need for parenteral fluids. Children use was measured by time from alternative modalities to achieve
doi:10.1542/peds.2008-3588 with severe dehydration, shock, initial catheter placement until rehydration.
or life-threatening illness were infusion began, the number of
Ease of use: Median time to
excluded. attempts required to place catheter,
SCRT infusion was 2 mins
and the number of site changes
Setting: Nine US hospital-based (0–15min). Fluid infusion began
or interruptions in flow. Safety
EDs 5 min. after catheter placement
and tolerability were measured by
in 45/51 (88%) of patients. SC
infusion site pain, reactions, or any
access was gained on first attempt
adverse events.
in 46/51 (90.2%) and in 5/51
Statistical analysis: Descriptive (9.8% ) on second attempt. Ten
statistics were used and reported in children had failed IV placement
frequency tables. attempts prior to enrollment in
the study. Investigators rated the
procedure as easy for 49/51 (96%)
of cases. Further, 45/49 (92%) of
the investigators rated SCRT as
equally or more effective than IV
rehydration; 4/49 (8%) rated it
less effective. Parent satisfaction
was measured with 90% satisfied
or extremely satisfied with the
procedure and 94% (45/48) felt
the procedure was successful and
would select that method for future
rehydration.
Safety and tolerability: Four
patients complained of insertion
site pain, other reactions rated
as minimal swelling, erythema,
and tenderness. Adverse events
occurred in 9 patients; most
were considered related to the
child’s illness; one had cellulitis
at the insertion site 20 hours
after the removal of the catheter.
Conclusion: SCRT is a safe,
effective, easy, and rapid option for
rehydration that is well tolerated by
both parents and patients.
17

Bahl, A., Pandurangadu, A. V., To determine if ED nurses trained Design: Convenience sample, non- Wilcoxon Rank-Sum Tests for Success rate IV-US 76% vs. 56% I II
Tucker, J., & Bagan, M. (2016). in US-guided IV placement have blinded, randomized controlled continuous data, IV-SOC techniques
A randomized controlled trial more success in placing IVs in trial with IRB approval N = 122 (n
Fisher Exact Test for categorical Success odds ratio IV-US 2.52
assessing the use of ultrasound for difficult access patients compared = 63 randomized for US group, n =
data times odds of success IV-SOC
nurse-performed IV placement in with nurses placing IVs using 59 randomized for SOC group)
(p = 0.02)
difficult access ED patients. The standard palpation techniques. Power analysis using Wilcoxon–
Criteria: Over 18 yrs; self-identify
American Journal of Emergency Mann–Whitney Test conducted for 1.52 IV attempts for IV-US
as difficult stick; episode of > 2 IV
Medicine, 34(10), 1950–1954. sample size.
attempts in previous visits; prior 1.71 IV attempts for IV-SOC
doi:10.1016/j.ajem.2016.06.098
hx of rescue catheter related to (p = 0.63)
inability to insert peripheral or Hx
of ESRD, IVDA, or sickle cell No significant difference in time
to achieve cannulation between
Setting: Single-site tertiary care, groups (p = 0.75)
level I trauma center ED
Bauman, M., Braude, D., & To evaluate the efficacy (success, Design: Two-phase prospective Measures: Primary and secondary Findings: The study did not 1 IV
Crandall, C. (2009). Ultrasound- time, # of punctures) and safety and systematically allocated non- outcomes measured include success find significant difference: the
guidance vs. standard technique in patient satisfaction of US-guided blinded cohort study. Expedited rate, # of punctures, time on task, traditional technique had 70.6%
difficult vascular access patients peripheral IV access by ED techs in IRB review and approval. satisfaction, use of additional success rate compared with US-
by ED technicians. The American patients with DIA access compared personnel, and complications. guided technique with an 80.5%
Method: Single-user technique
Journal of Emergency Medicine, with traditional methods. Statistical Analysis: Difference in success. Post hoc analysis assessing
using Sonosite Micromax or Titan
27(2), 135–140. doi:10.1016/j. phases analyzed using Newcombe– 3 attempts as failure resulted in
model US machines.
ajem/2008.02.005 Wilson hybrid. Unpaired t-tests a significantly improved success
Sample: Convenience adult ED were also used. Satisfaction was rate: CI 14.5%, US rate 80.5%
patients (N = 75) with difficult analyzed via Wilcoxon Rank-Sum and traditional 44.1%. US was 2
IV access as defined by 2 missed Test. times faster than control. US (26.8
attempts. minutes) took significantly less
Phase 1 (n = 34). PIV was via time to gain access compared with
traditional methods. EDT had control (74.8 minutes). Traditional
training on US-guided technique. technique required more skin
punctures (mean 3.6) compared
Phase 2 (n = 41) data collected on with US (mean 1.6). US-guided had
US-guided methods after training. higher patient satisfaction
Setting: 350 bed urban, university (70) compared with traditional
teaching hospital/trauma center methods (44).
Conclusion: After brief training
of EDT for PIV access, the use
of US guidance had same rate of
success as traditional methods,
significantly improved speed of
access, and reduced number of
skin punctures.
18

Blaivas, M., & Lyon, M. To measure the effect of US on Design: Prospective observational Measures: Perceived difficulty with Findings: A total of 258 (80%) of I III
(2006). The effect of ultrasound emergency nurses’ perceptions of study. IRB approved. US techniques and the # of blind the patients were considered “very
guidance on the perceived the difficulty of gaining PIV access attempts. Nurses rated attempts hard” starts, 59 “hard”, 3 “easy”
Method: Nurses introduced to US-
difficulty of emergency nurse- in ED patients. using US from “very hard” to “very and none were considered “very
guided PIV access in class prior to
obtained peripheral IV access. easy”. Short-axis and long-axis vein easy” before the use of US. After
study. Lab practice prior to study
Journal of Emergency Medicine, visualizations were also measured. US tutorial, 29 of the 258 “very
with blue phantom simulation, then
31(4), 407–410. doi:10.1016/j. hard” patients remained in the
attempted PIV using Sonosite US Statistical Analysis: Student t-Test
jemermed.2006.04.014 same category, 43 moved to “hard”,
machine and asked to complete was used for an analysis.
112 moved to “easy”, and 137 to
questionnaire. N = 321. Surveys
“very easy”.
completed by 23 RNs in a 5-month
period. Conclusion: Nurses’ perception
of US guidance for IV access in
Setting: Level 1 trauma center with
ED patients changed from “very
75,000 annual census.
difficult” to “easy” or “very easy”
Population: Not specified if adults after US training.
or peds
Brannam, L., Blaivas., M., To evaluate the effectiveness of Design: Prospective observational Data analysis used descriptive Findings: A total of 280 (87%) 2 VI
Lyon, M., & Flake, M. (2004). US-guided vascular access in an with a convenience sample. statistics utilizing statistical successful attempts. The 41 failures
Emergency nurses’ utilization of emergency department. Nurses received classroom and calculators from a commercially included 12 (29%) that required
ultrasound guidance for placement practical education with a survey available software package central lines, 9 (22%) that required
of peripheral intravenous lines of each US-guided vascular external jugular IVs, and 20
in difficult-access patients. attempt. Nurses were allowed to (49%) that received peripheral IV
Academy of Emergency Medicine, decline participation. Success was access placed under US guidance
11(12),1361–1363. doi:10.1197/j. determined by blood return and by another nurse or physician.
aem.2004.08.027 flushing fluids. IRB approved. Demographics of the patients
include 90 (28%) obese, 57 (18%)
Sample: N = 321 surveys were
with sickle cell anemia, 31 (10%)
collected over a five-month period
renal dialysis patients, 40 (12%)
Setting: A Level I trauma center were IV drug abusers, and 61 (19%)
with teaching facilities had unspeciﬁed chronic illness.
The remaining 38 had no stated
reason for difﬁcult access, with an
additional 4 patients with arterial
punctures.
19

Chapman, L. L., Sullivan, B., To test hypothesis that VeinViewer Design: Randomized controlled Measures: Primary end points were Findings: No significant 1 II
Pacheco, A. L., Draleau, C. P., & will decrease time to PIV trial. IRB approved. time to successful PIV, number differences between standard
Becker, B. M. (2011). VeinViewer- placement, number of attempts, and of attempts, pain level. Patient cannulation (SC) and VeinViewer
Method: Children aged 0 to 17
assisted intravenous catheter pain in pediatric ED. characteristics also reviewed. (VV). Findings could relate to skill
years who required a nonemergent
placement in a pediatric emergency and experience level of nurses.
PIV in a tertiary care pediatric Statistical analysis: Two-sample
department. Academic Emergency Decreased time to cannulation in
ED were randomized to one of t-test, ANOVA, appropriately
Medicine, 18(9), 966–971. < 2 years group. Conclusion: Skill
two groups: PIV cannulation powered.
doi:10.1111/j.1553-2712.2011.01155.x level of nurses may have influenced
(SC) or PIV cannulation with
results. VV may be more effective
the VeinViewer (VV). Pediatric
in a non-pediatric ED or with less-
emergency nurses placed all
experienced nurses. Further studies
IVs. Data were collected by an
needed to explore < 2 yr group
observing research assistant.
Sample: N = 323.
Setting: Midsize urban tertiary
pediatric ED
Chinnock, B., Thornton, S. L., & To determine how the choice Design: Prospective observational Documentation of the perceived Findings: Cannulation success 2 IV
Hendey, G. W. (2007). Predictors of vein, the reason for difficult study. IRB approved. difficulty of venous access: were the rate was 63%, of which 83% were
of success in nurse-performed access, or the one- vs. two-person veins sonographically visible; had successful on the first attempt;
Method: 18 nurses enrolled
ultrasound-guided cannulation. technique affected the success rate the patient needed previous central overall success rate was 53%.
patients.
Journal of Emergency Medicine, of nurse-performed US-guided venous access (added late in the The basilic vein had a better
33(4), 401–405. doi:10.1016/j. IV cannulation in patients with US-guided cannulation was study)? 90-minute training session cannulation success rate (70%)
jemermed.2007.02.027 difficult IV access. attempted after two failed of lecture, hands-on use of the UC, than the brachial vein (41%).
peripheral attempts and no short axis approach, 1- and 2-person Successful cannulation occurred in
other visible potential sites for technique. Documentation of a flash users of IV drugs 62% of the time;
cannulation. of blood and cannulation success 62% success for obese patients and
Sample: Convenience sample of (defined as remained in place until 64% for patients with multiple prior
adults. 100 subjects of a largely completion of therapy). medical problems. Cannulation
low-income population. Attempt N success rate for one-person
= 119; patient success n = 100. technique was 66% and 72% for
two-person technique
Setting: Urban academic center
with an annual ED volume of
60,000 visits
20

Costantino, T. G., Kirtz, J. F., & To determine which initial Design: Prospective randomized Primary endpoint was successful Findings: Success rate for the US- 1 II
Satz, W. A. (2010). Ultrasound- approach by emergency physicians controlled trial performed by 2nd- cannulation defined as aspiration guided arm was 84% vs. 50% for
guided peripheral venous access (ultrasound-guided peripheral and 3rd-year emergency medicine of 5 mL of blood and infusion of the EJ arm, which is statistically
vs. the external jugular vein as IV access vs. external jugular residents who had completed at IV solution. Secondary endpoints significant. Overall success after
the initial approach to the patient vein cannulation) is more readily least 5 successful external jugular were the number of successfully cross-over data were considered
with difficult vascular access. The successful in patients with difficult (EJ) insertions and 5 US-guided cannulated IV lines by each was 89% for USIV and 55% for EJ.
Journal of Emergency Medicine, IV access. peripheral IV cannulations. technique, time to cannulation, Time to cannulation for USIV was
39(4), 462–467. doi:10.1016/j. Completed emergency US rotation functioning lines at the conclusion 8.9 min vs. 8.1 min for EJ.
jemermed.2009.02.004 with 16 hours didactic and at least of ED treatment, and observed
89% of US-IVs were functioning at
150 US scans. Cross-over pathway complications. Success rate
the conclusion of ED treatment vs.
utilized if the subject failed the first comparisons were measured with
93% of EJ lines. No complications
arm randomized to. Fisher’s exact methods. Time
were observed in either group.
data and age were compared with
Sample: All ED patients who
Mann–Whitney U or Student’s Conclusion: US-IV statistically
failed at least 3 nursing attempts
t-Test methods. superior to EJ IV cannulation
at peripheral IV access. Minimum
age 18 years. Patients needing a
central line were excluded. n = 32
in the US-guided arm; n = 28 in the
EJ arm.
Setting: Urban, tertiary-care
university hospital ED (60,000
annual ED visits)
Costantino, T. G., Parikh, A. K., To compare US-IV with traditional Design: Prospective, non- Measures: IV success rate, time to Findings: US-guided PIV was more 2 VI
Satz, W. A., & Fojtik, J. P. (2005). PIV access in difficult-to-obtain blinded, systematically allocated first successful cannulation, time successful (97%) than traditional
Ultasonography-guided peripheral IV (defined as 3 missed attempts) comparison study. IRB approved. for request to cannulation, number methods (33%), required less time
intravenous access versus performed by experienced ED RN. of attempts, patient satisfaction, and (13 minute vs. 30), decreased
Method: ED residents performed
traditional approaches in patients complications number of punctures (1.7 vs. 3.7),
2-user technique using either
with difficult intravenous access. and improved patient satisfaction
Seimens Versapro or Sonosite Statistical analysis: Descriptive,
Annals of Emergency Medicine, (8.7 vs. 5.7).
machines for US-guided technique. SD, Mann–Whitney U, analysis
46(5),456–461. doi:10.1016/j.
EJ was included in traditional of variance
technique methods. Sample:
Convenience sample (N = 60)
randomized according to odd
(n = 39) or even (n = 21) day.
Pediatric and pregnant patients
were excluded. Inclusion criterion
was inability to gain access in 3
attempts or based on prior history,
obesity, IV drug use, or chronic
medical conditions.
Setting: Urban tertiary university
ED
21

Curtis, S. J., Craig, W. R., Logue, To compare success rates of Design: Stratified, parallel-group Used VeinViewer GS for NIR; Findings: Success of IV on 1st 2 II
E., Vandermeer, B., Hanson, A., IV initiation using NIR, US, or RCT with approval from Health M-Turbo by Sonosite for US. ED attempt: no significant findings
& Klassen, T. (2015). Ultrasound standard technique. Research Ethics Board. nurses were trained on using NIR between NIR, US, and standard
or near-infrared vascular imaging and US devices prior to study. techniques. 70.8% US; 65.9%
Sample: N = 418 randomized
to guide peripheral intravenous Power analysis conducted for NIR; 74.7% standard with p =
convenience sample (2 arms:
catheterization in children: A sample size. SAS and StatXact 0.3. Relative risk 0.95 US; 0.88
< 3 yrs, n = 135; > 3 yrs, n =
pragmatic randomized controlled used for data analysis. Used NIR, compared with standard.
283). Each arm was divided into
trial. Canadian Medical Fisher–Freeman–Halton Exact Test No significant difference in mean
3 groups (NIR, US, standard
Association Journal, 187(8), for comparison of dichotomous number of attempts between NIR,
technique). < 3 yrs group:
563–570. doi:10.1503/cmaj.141012 data. Used Kruskal–Wallis Test or US, standard techniques (US = 1.4;
NIR n = 43; US n = 42; standard
one-way analysis for means, SD, NIR = 1.58; standard = 1.43). No
n = 50. > 3 yrs group: NIR n = 92;
medians. CI 95%. Conducted Wald significant findings in mean time
US n = 95; standard n = 96. Power
Test for same nurses performing on for tourniquet to access (US = 8.3
analysis conducted for sample size.
multiple patients. ± 15.9; NIR = 7.8 ± 11.0; standard =
Population: 0–16 yrs.
6.5 ± 10.3 for p = 0.5. Children < 3
Setting: Children’s Hospital ED yrs - NIR performed the worst.
in Alberta, Canada, with 45,000
visits/year, June 2010 through
August 2012
Egan, G., Healy, D., O’Neill, H., Systematic review and meta- Design: Meta-analysis and Primary outcome was successful Findings: Ultrasound guidance 1 I
Clarke-Moloney, M., Grace, P. A., analysis to evaluate the systematic review of MEDLINE PIV insertion. Secondary outcomes increased the likelihood of
& Walsh, S. R. (2013). Ultrasound effectiveness of ultrasound- and EMBASE databases were time to successful PIV successful cannulation in difficult
guidance for difficult peripheral guided peripheral IV cannulation cannulation and number of skin access patients. However, USGIV
Sample: Identified 15,405 citations,
venous access: Systematic review compared with standard technique punctures. Study conducted in had no significant effect on time
assessed 62 abstracts for eligibility,
and meta-analysis. Emergency in patients known to have difficult accordance with the Preferred to cannulation or number of
and included 7 RCTs in meta-
Medicine Journal, 30(7), 521–526. access. Reporting Items for Systematic punctures.
analysis for a total of 289 patients.
doi:10.1136/emermed-2012-201652 Reviews and Meta-Analysis
All age groups included. (PRISMA) guidelines. Study
quality was measured using Jadad
score. Statistics: Random effects
models; Cochran’s Q Test, Egger’s
Test
22

Fink, R. M., Hjort, E., Wenger, To determine whether dry versus Design: Two-group, randomized Measures: Number of IV insertion Findings: Dry heat was 2.7 times 1 II
B., Cook, P. F., Cunningham, moist heat application to the upper controlled trial. IRB approved. attempts, time to achieve IV more likely to result in successful
M., Orf, A., & Zwink, J. (2009). extremity improves IV insertion insertion post-heating, patient IV insertion. The difference in
Methods: Towels were heated to
The impact of dry versus moist rates. anxiety levels pre- and post-heating, mean insertion time between dry
160 °F using the Getinge 5524
heat on peripheral IV catheter and patient comfort. heat (98.5 seconds, SD 57.6) and
warming cabinet for dry heat and
insertion in a hematology-oncology moist heat (127.6 seconds, SD
to 178 °F in the Equipro Spa-Cabi Statistical analysis: Descriptive
outpatient population. Oncology 86.1) was considered clinically
61101 (Sundries Novelty Inc) for analysis, t-tests, chi-squared,
Nursing Forum, 36(4), E198–E204. meaningful. Moist heat had greater
moist heat. Skin temperature was ANCOVA.
doi:10.1188/09.ONF.E198-E204 increase in temperature than dry
monitored using Mon-a-therm 4070
heat (p < 0.001) when applied to
(Nellcor Puritan Bennett LLC).
hand or forearm. Participants rated
Sample: N = 136 adult hematologic higher anxiety for dry heat (17, SD
outpatients with cancer or other 22.2) compared with moist heat
malignancies (10.9, SD 15.6). Participants rated
Setting: An academic cancer comfort significantly higher for dry
infusion center in Colorado heat (−8.32) compared with moist
heat (−4.41) (p = 0.0159).
Conclusions: Dry heat preferred
because of low cost, safety to
patients, and feasibility.
Forbat, L., Kunicki, N., Chapman, To identify ways in which sub Design: Systematic review using Authors had a protocol for Findings: Concluded that there is 2 V
M., & Lovell, C. (2017). How Q fluids are administered to those PRISMA guidelines. IRB not extracting data and confirming lack of evidence regarding site,
and why are subcutaneous fluids with advanced illness. Focused needed. quality ratings. Findings were volume, rate, and mode of infusion
administered in an advanced illness primarily on people at end of not pooled and analyzed but for sub Q fluids, leaving clinicians
Sample: N = 14
population: A systematic review. life, but not all were in hospice/ summarized narratively because with little to guide them.
Journal of Clinical Nursing, palliative care. studies were of different designs.
26(9–10), 1204–1217. doi:10.1111/
jocn.13683
Heinrichs, J., Fritze, Z., Systematic review and meta- Design: Meta-analysis and Primary outcomes included PIC Findings: USG IV may reduce 1 I
Vandermeer, B., Klassen, analysis to evaluate US guidance systematic review of MEDLINE, success rates, # of attempts, time PIV attempts and procedure time
T., & Curtis, S. (2013). as an aid to PIV insertion. Cochrane Central Register of for procedure and time from in pediatric ED and OR patients.
Ultrasonographically guided Controlled Trials, EMBASE, randomization to PIV success. Few studies’ outcomes reached
peripheral intravenous cannulation Cumulative Index to Nursing Instruments: The Preferred statistical significance. Larger,
of children and adults: A systematic and Allied Health Literature Reporting Items for Systematic well-controlled studies needed for
review and meta-analysis. (CINAHL), Web of Science, Reviews and Meta-Analysis; evidence-based recommendations.
Annals of Emergency Medicine, ClinicalTrials.gov, and Google.ca. Cochrane Risk of Bias Tool.
61(4), 444–454.e1. doi:10.1016/j. Statistics: IQR, RRR, I2 statistic
Sample: identified 4,664 citations,
assessed 403 full texts for
eligibility, and included 9 trials.
Five had low risk, 1 high risk, and 3
unclear risk of bias. All age groups
included.
Setting: ED and OR setting.
23

Huff, L., Hamlin, A., Wolski, To investigate whether the Design: Descriptive, IRB approved. Measures: Wong–Baker FACES® Findings: The overall differences 2 IV
D., McClure, T., Eliades, A. B., application of heat to a child’s Informed consent obtained from Pain Scale. IV size measured by in average vein measurement
Weaver, L., & Shelestak, D. (2009). potential intravenous (IV) site after parent/legal guardian for all SonoSite iLook 25. Warming device across the three times were
Atraumatic care: EMLA cream the application of EMLA Cream™ subjects. Assent was sought from was DeRoyal Infant Heel Warmer. statistically significant: F (2.58)
and application of heat to facilitate decreases vasoconstriction as a subjects aged 10–12 years. PI-developed Vein Visibility Scale = 30.4, p <0.001. The overall
peripheral venous cannulation in method to promote atraumatic to assess the difficulty of vein differences in average visualization
Sample: Convenience sample
children. Issues in Comprehensive care in the hospitalized pediatric visualization (1 = easily visible, across the three times were
(N = 30) of Caucasian children
Pediatric Nursing, 32(2), 65–76. patient. 2 = somewhat visible, and statistically significant: F (2.58)
ranging in age from 8–12 years
doi:10.1080/01460860902737418 3 = not visible). Vein visibility was = 40.02, p < 0.001. The study had
with medical or surgical diagnoses
assessed prior to EMLA Cream™ an 80% first cannulation rate. The
requiring IV insertion and who
application, one hour after EMLA baseline mean vein size was 0.243
were hospitalized on the school-age
Cream™, and two minutes after cm, which decreased to 0.205 cm
unit at a children’s hospital.
heat application to evaluate the after EMLA Cream™ application.
Exclusions: non-Caucasian, effectiveness of heat on vein size With heat application, the vein
developmentally delayed, and and visibility. size increased to 0.253 cm. This
dehydrated or those requiring corresponded to increased vein
Statistical analysis: a one-way
vasoactive meds. size and visibility when heat
repeated measures ANOVA was
Setting: 250-bed pediatric hospital applied, which counteracted the
used for the two outcome variables.
vasoconstrictive effect of EMLA
Cream™.
Conclusion: The application of
heat counteracts vasoconstriction
associated with EMLA Cream™.
Kuensting, L. L. (2013). Comparing To evaluate difference in infusion Design: Retrospective descriptive Primary outcomes were order time The IV/SC group had significantly 2 VI
subcutaneous fluid infusion with start times and # of attempts study. Sample: Medical records to infusion start time, number of longer time to infusion (U = 0.000;
intravenous fluid infusion in between initial SC and IV were reviewed for 36 children from SC and IV attempts, disposition. p < 0.001) and significantly more
children. Journal of Emergency infusions. Also, if SC fluids were November 2008 to May 2010 who Statistical analysis: Frequency needlesticks (Z = 0.000; p < 0.001).
Nursing, 39(1), 86–91. doi:10.1016/j. initially started, was PIV access had received SC fluids only or distributions, Mann–Whitney and
Concluded that SC infusions
jen.2012.04.017 improved? received SC fluids after 2 or more Wilcoxon Tests
may aid parenteral rehydration in
failed IV attempts. Setting: Large
non-seriously ill children while
suburban pediatric ED
minimizing number of needlesticks
needed to complete the infusion.
24

Leidel, B. A., Kirchhoff, C., To compare time to establish IO vs. Design: Prospective observational Primary outcomes were success Findings: IO placement was faster 1 VI
Bogner, V., Braunstein, V., CVC in adult resuscitation patients. study. IRB approved. rate and procedure time. and failure rates were significantly
Biberthaler, P., & Kanz, K. lower in IO sites.
Methods: Investigated success Statistics: Chi-squared, z test,
G. (2012). Comparison of
rates on first attempt and procedure 2-sided Mann–Whitney Rank Sum Conclusion: IO vascular access is
intraosseous versus central venous
times of IO access vs. central Test; appropriately powered a reliable bridging method to gain
vascular access in adults under
venous catheterization (CVC) in vascular access for in-hospital
resuscitation in the emergency
adults (≥ 18 years of age) with adult patients under resuscitation
department with inaccessible
inaccessible peripheral veins under with difficult peripheral veins.
peripheral veins. Resuscitation,
trauma or medical resuscitation. Moreover, IO access is more
83(1), 40–45. doi:10.1016/j.
efficacious, having a higher success
resuscitation.2011.08.017 Sample: Convenience sample of
rate on first attempt and a lower
consecutive adult patients under
procedure time compared with
resuscitation that had inaccessible
landmark-based CVC.
peripheral veins (N = 40)
Setting: Urban level I academic
trauma center
Leidel, B. A., Kirchhoff, C., To compare intraosseous (IO) vs. Design: Prospective observational Mann–Whitney Rank Sum Test Findings: Success rate on first 1 VI
Bogner, V., Stegmaier, J., central venous catheter (CVC) study. Ethics approved. PIV applied to analyze the differences in attempt was 90% for IO vs. 60% for
Mutschler, W., Kanz, K. G., access in terms of success rate on attempted three times for a procedure times. Significance level CVC. Mean time for cannulation
& Braunstein, V. (2009). Is first attempt and procedure time. maximum of 2 minutes, then of p = 0.05. was significantly shorter for IO
the intraosseous route fast simultaneous IO and CVC access (2.3 ± 0.8 min.) vs. CVC (9.9 ± 3.7
and efficacious compared to attempted by two participants. min). One IO failure related to not
conventional central venous A third observer timed each reaching the bone marrow owing to
catheterization in adult patients procedure. Procedure time defined incorrect insertion site. Four CVC
under resuscitation in the as duration of picking up set for failures where the guidewire would
emergency department? A IO/CVC access through successful not advance into the vessel.
prospective observational administration of drugs or infusion.
Conclusion: IO was significantly
pilot study. Patient Safety
Sample: Convenience sample of more successful and required
in Surgery, 3(1), 24–31.
consecutive critically injured or ill significantly less time than CVC.
doi:10.1186/1754-9493-3-24
patients 18 years of age and over
who needed immediate vascular
access. N = 10.
Setting: Urban level I trauma
center
25

Lenhardt, R., Seybold, T., To determine whether local Design: Single-blinded prospective Measures: 1) success rate of Findings: Neurosurgical patients 2 II
Kimberger, O., Stoiser, B., & warming of lower arm and hand randomized controlled trial 18-gauge cannula into hand; had time to insertion of 36 seconds
Sessler, D. I. (2002). Local facilitates peripheral venous and single-blinded randomized 2) time to successful cannulation. in the active warming group and
warming and insertion of access. crossover trial. IRB approved. 62 seconds in the passive warming
Statistical analysis: Unpaired
peripheral venous cannulas: Single group (p = 0.002). Three (6%)
Methods: Neurosurgical patients two-tailed t-tests and chi-squared.
blinded prospective randomised first attempts failed in the active
had carbon fiber warming device p < 0.05 considered a significant
cntrolled trial and single blinded warming group compared with
(PI-developed) applied for difference.
randomised crossover trial. BMJ, 14 (28%) in the passive insulation
15 minutes. Patients randomly
325(7361), 409–410. doi:10.1136/ group (p = 0.008). The crossover
assigned to have warmer powered
bmj.325.7361.409 study with hematology patients
on for study; control was not
resulted an insertion time reduced
powered on. Hematology patients
by 20 seconds (p = 0.013) with
had 10-minute intervention.
active warming and failure rates
Sample: Adult neurosurgical at first attempt were 6% with
patients (n = 100) and leukemia warming and 30% with passive
patients (n = 40). insulation (p < 0.001).
Setting: Neurosurgical and Conclusion: Active warming
hematology units in a university improves first-time cannulation
hospital ward success by reducing time and
number of required attempts.
Liu, Y. T., Alsaawi, A., & Systematic review to evaluate the Design: Systematic review of Primary outcome was success rate Findings: Routine use of US- 1 I
Bjornsson, H. M. (2014). effect of using ultrasound-guided MEDLINE, SCOPUS, Google of PIV cannulation. Secondary guided IV placement for difficult
Ultrasound-guided peripheral peripheral IV cannulation in Scholar, Cochrane Central Register outcomes were time to successful access is not supported by current
venous access: A systematic review patients with difficult IV access. Archive, WHO International PIV cannulation and number of research. Greatest benefit in
of randomized-controlled trials. Clinical Trials Registry, attempts. success rate is seen in patients
European Journal of Emergency CINAHL, and society conference where the vein is not palpable or
Study conducted in accordance
Medicine, 21(1), 18–23. doi:10.1097/ proceedings. visible. The greatest benefit in time
with the Preferred Reporting Items
MEJ.0b013e328363bebc to success and number of attempts
Sample: Identified 1,778 titles, for Systematic Reviews and Meta-
is seen in pediatric patients with
50 studies had full text analysis (PRISMA) guidelines.
difficult access.
comprehensive review, and
included 6 RCTs in meta-analysis
for a total of 316 patients (153 in
control group and 163 in US-
guided group). All ages included.
26

McCarthy, M. L., Shokoohi, H., To determine whether initial line Design: RCT, 2-group parallel Primary outcome was success Findings: 73% of lines placed in 1 II
Boniface, K. S., Eggelton, R., placement has a higher success rate design, IRB approved. Techs start on initial or second insertion AC. Initial success rate 81%, varied
Lowey A., Lim, K., . . . Zeger, using landmark or US-guidance in IVs in ER and are trained in use of attempt; secondary outcomes greatly by technique and level of
S. L. (2016). Ultrasonography patients with difficult, moderately US machine. Training described. were occurrence of complication, access difficulty. US 1st-attempt
versus landmark for peripheral difficult, or easy access. SAS-randomized patients to patient-reported pain of procedure success 82–86% regardless of
intravenous cannulation: A Hypothesized that initial success landmark or US groups stratified on 0–10 scale, duration of attempt difficulty level. Landmark 1st
randomized controlled trial. rate would be at least 5% higher by technique and level of difficulty. from tourniquet to flushing with attempt success varied 35–97%
Annals of Emergency Medicine, using US in difficult or moderately Used block randomization of NS; one attempt defined as one by level of difficulty. When using
68(1), 10–18. doi:10.1016/j. difficult access patients and no patients into groups of 6 to ensure needle puncture; start successful if US., 1st attempt success 48%
annemergmed.2015.09.009 different among patients with easy treatment was distributed equally flushed with NS and no infiltration; (95% CI 35.6–60.3), higher in
access. by stratum. If 1st attempt failed, appropriate analysis difficult access, and 10.2% higher
patient randomized again. (95% CI 1.7–18.7) in mod difficult
access. In patients with easy
Sample: Included adult patients
access, 10.6% higher success rate
capable of giving consent who
(95% CI 5.8–15.4) when using
would need peripheral IV (not
landmark technique. More skilled
in hand), excluded all ESI 1, and
techs had better 1st-attempt
ESI 2 patients for whom it was
success using US in difficult
dangerous to delay care; techs were
access pts (9.4%, 95%CI 2.5–16.3);
also consented. N = 1617
9.7% in mod diff access (95% CI
Setting: Urban academic ER 2.8–16.6), and 7.9% in easy access
(95% CI 2.1–13.7) No sig diff in
complications by method
of insertion.
Conclusion: When a vein can be
seen or palpated, landmark is a
superior method of successful
insertion. In easy access pts,
landmark had an 11% higher first-
attempt success rate. In pts where
a vein cannot be seen or palpated,
US is more successful: 10% more
successful on 1st attempt when US
used in pts with mod diff access,
and 48% more successful in pts
with diff access. There is therefore
a large benefit with US use in pts
with difficult access.
27

McNeely, H. L., Ream, T. L., To determine if the use of Design: Longitudinal experimental Used researcher-developed Findings organized by hypothesis: 2 II
Thrasher, J. M., Dziadkowiec, VeinViewer will: 1) Increase with randomized participants, questionnaire and appropriate
1) No significant differences
O., & Callahan T. J. (2018). nurses’ perceived skills and non-blinded; power analysis done statistical analyses.
between groups in average
Utilization of a biomedical device ability in starting IV; 2) Increase (needed a total of 200 starts) + IRB.
perceived skill pre and post
(VeinViewer®) to assist with perceived confidence in starting All participants educated in proper
(W = 78, p = 0.55 pre; W = 83,
peripheral intravenous catheter IVs; 3) Increase initial attempt procedure. Nurses recruited (40)
p = 0.76 post)
(PIV) insertion for pediatric nurses. success rate compared with were randomized to VeinViewer
Journal for Specialists in Pediatric standard practice; 4) Decrease or standard practice, A pre-survey 2) No significant difference in
Nursing, 23(2), 1–8. doi:10.1111/ number of overall attempts at of experience, perceived skill, perceived confidence between
jspn.12208 insertion compared with standard and confidence done prior to groups pre or post (W = 90, p = 1
practice; 5) Decrease cost of study start. Each month during pre; W = 87, p = 0.56 post)
insertion compared with standard the study, participants answered 3) No significant differences
practice; 6) Decrease time two questions on perceived skills between groups in average success
associated with insertion compared and confidence, and then they did rate of IV attempt (p = 0.72). The
with standard practice. a final survey. Study lasted 15 trend appears to show that the
months. VeinViewer group had higher
Sample: Convenience sample (1st success rates at the end of the
40 volunteers), 17–18% attrition, study, but this was not significant
n = 27 data sets were analyzed (p = 0.62).
because 6 participants did not 4) Similar trends in the average
complete enough IV starts. (Does number of attempts, with no
not state the actual # of IV attempts significant differences pre or post
analyzed; eliminated cases where (p = 1; p = 0.62)
5 or less were attempted.) Each
participant was to start 10 IVs. 5) Standard practice used 1291
Setting: Nurses working in acute items, VeinViewer group used 995
care peds items. No significant differences
in number of items used or cost
between groups (W = 95, p = 0.83;
W = 90, p = 1).
6) No significant differences in
time to start IV between groups.
They found that nurses lower on
the clinical ladder had higher
perceived skill and confidence.
28

Paxton, J. H., Knuth, T. E., & To test hypothesis that proximal Design: Prospective cohort Patients who required venous Findings: First attempt success 1 III
Klausner, H. A. (2009). Proximal humerus intraosseous (PHIO) study. IRB approved. All access and arrived without adequate rates: 73.7% (PIV); 20% (CVC);
humerus intraosseous infusion: would be faster and easier than study participants underwent venous access were included. 80.6% (PHIO). Mean time to flow
A preferred emergency venous conventional venous access for the educational training in-services Phase 1 consisted of data reflecting in minutes: 3.6 (PIV); 15.6 (CVC);
access. The Journal of Trauma, emergent resuscitation of critically and standardized testing on IO time to first catheter placement 1.5 (PHIO). Mean pain score
67(3), 606–611. doi:10.1097/ ill or injured patients. catheter placement, management, (PIV or CVC), perceived pain, for insertion: 0.9 (PIV); Unable
TA.0b013e3181b16f42 and removal. complications, resuscitation (CVC); 4.5 (PHIO). Mean pain
medications given. Phase 2 score infusion 0 (PIV); Unable
Sample: N = 62. Phase 1 included
consisted of patients who required (CVC); 3.8 (PHIO). Mean time to
57 PIV and 5 CVC; Phase 2
a new vascular access during good flow is significantly faster
included 29 PHIO catheterizations.
resuscitation and underwent PHIO. for PHIO. No major complications
Setting: Urban Level I trauma All patients in Phase 2 received a noted. Results demonstrate that
center with an annual ED census standard dose of lidocaine before PHIO placement is quick and easy
of 92,000 IV infusion. alternative for venous access.
Perry, A. M., Caviness, A. C., To determine if use of near- Design: Non-blinded, randomized Measures: Time required to Findings: The first attempt success 2 II
& Hsu, D. C. (2011). Efficacy of infrared light (VeinViewer, controlled trial. IRB approved. successfully cannulate vein. rate was not significantly different
a near-infrared light device in Luminetx Corporation, Memphis Sample: N = 123 patients younger Primary outcome measure was first with the use of near-infrared light
pediatric intravenous cannulation: TN) venipuncture aid improved than 20 years whose clinical attempt success rate. Statistical compared with no light.
A randomized controlled the rate of successful first-attempt presentation required IVs stratified analysis: Frequencies and CI
trial. Pediatric Emergency placement of IV catheters by nurses to three groups by RN experience
Care, 27(1), 5–10. doi:10.1097/ (defined as clinically important of 5-year intervals then randomized
PEC.0b013e3182037caf difference of 20%). to (62) standard (control) or (61)
device (infrared).
Setting: Urban pediatric ED
Remington, R., & Hultman, Primary objective was to assess Design: Identification and appraisal Measured the safety, efficacy and Findings: Safety: HDC found 2 V
T. (2007). Hypodermoclysis the safety and efficacy of of one systematic review, two feasibility of HDC vs. IV therapy to be comparable with IV
to treat dehydration: A review hypodermoclysis (HDC) in the randomized controlled trials, and and HDC alone. administration. Systemic adverse
of the evidence. Journal of treatment of mild to moderate six cohort studies. effects incidence and major local
the American Geriatrics dehydration. Secondary object adverse effects did not differ
Sample: Subjects were elderly, with
Society, 55(12), 2051–2055. was to compare HDC to IV fluid between the two groups. Mild local
mean ages of 71 to 85 years.
doi:10.1111/j.1532-5415.2007.01437.x replacement for feasibility. adverse effects occurred more
Setting: Residents were in long- frequently with IV than HDC.
term care centers, acute geriatric
Efficacy: HDC and IV equally
units, hospice, and/or palliative
effective. More subjects improved
care environment.
clinically and generally with
IV than with HDC, though
not statistically significant.
Improvements in lab indicators
of dehydration were similar in
both groups.
29

Rothbart, A., Yu, P., Müller- To determine if the use of a Design: Quasi-experimental Statistical analysis: SPSS Findings: No significant difference 3 IV
Lobeck, L., Spies, C. D., Wernecke, near-infrared device (Accuvein) retrospective study with IRB v. 18 was used for analysis with in demographics or population
K. D., & Nachtigall, I. (2015). improves the initiation time and approval. IV cannulations by 95% CI limits; chi-squared and samples between intervention
Peripheral intravenous cannulation number of attempts for IV access in anesthesiologists, nurses, and nonparametric testing used for and control groups. Intervention
with support of infrared laser vein pediatrics. residents who were trained on the demographic analysis. group’s use of EMLA Cream™
viewing system in a pre-operation use of Accuvein by an anesthetist higher (p = 0.003). Successful
setting in pediatric patients. trained by the manufacturer. cannulations within 2 min for
BMC Research Notes, 8(1), 463. Accuvein 300 used for intervention intervention group and within
doi:10.1186/s13104-015-1431-2 group; BD Insyte Autoguard 1 min for control group (p < 0.01).
Winged 24-g and 26-g. IV Rate of success on first attempt
caths were used for access in all was 0.45 for the intervention group
participants. vs. 0.73 in the control group
(p < 0.01). No significant reduction
Sample: N = 236 pediatric
in initiation time or number of
patients 0–17 yrs undergoing
attempts using Accuvein. Results
a surgical intervention: 114 in
of study were compared to previous
intervention group, 124 in control
studies with similar results.
group. Participants were selected
consecutively for each group. Once
intervention group sample was
met, control sample group was
started. Setting: Surgical Services
(Department of Anesthesiology and
Intensive Care) in Berlin
Schreiber, S., Cozzi, G., Patti, G., To determine if heat application Design: RCT. IRB – parental Statistical analysis: Multivariate Findings: 88% success in heat 1 II
Taddio, A., Montico, M., Pierobon, after removing EMLA Cream™ at written consent. Not blinded. logistic group; 89% success in control;
C., & Barbi, E. (2018). Does the the site of venipuncture increases heat did not help with first-attempt
Method: EMLA applied and regression analysis; p value less
Application of heat gel pack after the procedure success rate. success rate with EMLA for
computer-generated random than 0.05 considered significant;
eutectic mixture of local anesthetic experienced staff (p = 0.081).
number then placed in envelope. control group, EMLA Cream™;
cream improve venipuncture or
After 60 minutes, EMLA removed study group, EMLA + heat. No significant difference in success
intravenous cannulation success
and envelope opened to determine between groups.
rate in children? A randomized
heat application. Measured first
control trial. Pediatric Emergency
attempt success.
Care, 34(2), e24–e27. doi:10.1097/
PEC.0000000000001248 Secondary outcomes: Vein
visibility using DIVA score
and pain score using FLACC or
W–B faces. Convenience sample
randomized to study arm with 200
in each arm. N = 400.
Setting: Pedi ED. White children
ages 1–19.
30

Scoppettuolo, G., Pittiruti, M., To determine if insertion of an Design: Retrospective analysis, Primary outcomes were success of Findings: 100% success rate of 2 VI
Pitoni, S., Dolcetti, L., Emoli, A., 8–10 cm catheter using direct per the hospital policy, IRB insertion, number of attempts, and insertion, zero complication
Mitidieri, A., . . . Annetta, M. G. Seldinger technique and ultrasound exempt, vein visualized with time to complete procedure.
Conclusion: When a peripheral
(2016). Ultrasound-guided “short” might increase the success rate of US and punctured with 8-10 cm
IV is needed in a patient with
midline catheters for difficult IV insertion. polyurethane catheter inserted
poor venous access, use of longer
venous access in the emergency using direct Seldinger technique,
catheter and US guidance is
department: A retrospective guidewire inserted through needle,
feasible and successful.
analysis. International Journal of and as needle removed, catheter
Emergency Medicine, 9(3), 1–7. is advanced over guidewire.
doi:10.1186/s12245-016-0100-0 Placement confirmed by blood
return.
Sample: N = 76 pts 18 and older
who required PIV but with difficult
venous access (no visible or
palpable veins, > 2 failed sticks).
Those needing central line access
were excluded.
Setting: ED university hospital in
Italy
Simhi, E., Kachko, L., To determine if use of a vein entry Design: Randomized PIVC with Measures: Number of attempts to Findings: Overall time to 2 II
Bruckheimer, E., & Katz, J. (2008). indicator device (VEID) facilitates the VEID or standard PIVC; successful IV cannulation; rate of cannulation of the vein was a
A vein entry indicator device for peripheral IV access in children. 22-g cannula inserted into an success at first attempt; and time mean of 9.1 seconds in the VEID
facilitating peripheral intravenous extremity. One senior pediatric required for IV cannulation. group vs. 22.5 in the control
cannulation in children: A anesthesiologist evaluated the vein group. Successful cannulation was
Statistical analysis: Data analyzed
prospective, randomized, selected; a second cannulated; a attained on the first attempt in 91%
with BMDP Statistical software.
controlled trial. Anesthesia and third recorded results. of the VEID group vs. 69% in the
p value ≤ 0.05 taken as significant.
Analgesia, 107(5), 1531–1535. control group. Average number of
Sample: 202 well children in same-
doi:10.1213/ane.0b013e318185cdab attempts in the VEID group was
day surgery. Ages 3 mos. to 17 yrs.
1.1 vs. 1.34 in the control group.
Setting: Major tertiary hospital NOTE: Device not available in the
U.S.
31

Spandorfer, P. R., Mace, S. E., To evaluate whether rHFSC fluid Design: Prospective randomized Primary outcomes: Mean total Findings: In mild to moderately 2 III
Okada, P. J., Simon, H. K., Allen, can be safely and effectively controlled study. volume infused in ED plus dehydrated children, rHFSC
C. H., Spiro, D. M., . . . INFUSE- administered to children who have hospital. Secondary outcomes was inferior to IV hydration for
Methods: The study included mild
Peds II Study Group (2012). mild to moderate dehydration were total infusion volume in ED, the primary outcome measure.
to moderately dehydrated children
A randomized clinical trial of in volumes similar to those administration time, improvement However, rHFSC was noninferior
(Gorelick dehydration score) aged
recombinant human hyaluronidase- delivered intravenously. Phase IV in dehydration and pain scores. in the ED phase of hydration.
1 month to 10 years. They were
facilitated subcutaneous versus noninferiority trial. Additional benefits of rHFSC
randomized to receive 20 mL/kg Statistics: Descriptive statistics
intravenous rehydration in mild to included time and success of
of isotonic fluids using rHFSC or
moderately dehydrated children in line placement, ease of use,
IV therapy over 1 hour and then as
the emergency department. Clinical and satisfaction. SC hydration
needed until clinically rehydrated.
Therapeutics, 34(11), 2232–2245. facilitated with rHSFC represents
doi:10.1016/j.clinthera.2012.09.011 Sample: 148 children aged 1 a reasonable addition to the
month–10 years treatment options for children who
Setting: 28 US hospitals and one have mild to moderate dehydration,
urgent care clinic especially those with difficult IV
access.
Stolz, L. A., Stolz, U., Howe, C., Systematic review and meta- Design: Meta-analysis and Primary outcome was PIV success Findings: Ultrasound guidance 1 I
Farrell, I. J., & Adhikari, S. (2015). analysis to determine whether systematic review of MEDLINE, rate. Secondary outcomes included increased the likelihood of
Ultrasound-guided peripheral success rates, time to cannulation, Web of Science, The Cochrane time to successful cannulation and successful cannulation in difficult
venous access: A meta-analysis and and number of punctures required Library, ClinicalTrials.gov, number of attempts. access patients. However, US-
systematic review. The Journal of for peripheral venous access EMBASE, Cumulative Index to guided IV had no significant effect
Used random effects models,
Vascular Access, 16(4), 321–326. are improved with US guidance on time to cannulation or number
Nursing and Allied Health estimates of heterogeneity from
doi:10.5301/jva.5000346 compared with traditional of punctures.
Literature (CINAHL), and Allied the Mantel–Haenszel Model to
techniques in patients with difficult
Health Literature. estimate pooled odds ratio for
peripheral venous access.
success, weighted mean difference
Sample: Identified 4,638 articles
for number of punctures, and time
with 960 duplicates. 3,634 articles
to cannulation.
excluded. Assessed 64 full text
articles for inclusion and included
6 RCTs and 1 prospective study.
All ages included.
32

Szmuk, P., Steiner, J., Pop, R. B., To test hypothesis that VeinViewer Design: Prospective randomized Primary outcomes: First attempt Findings: First-attempt cannulation 2 II
Farrow-Gillespie, A., Mascha, improves cannulation success by controlled trial. IRB approval success; secondary outcome: impact success was 47% in patients
E. J., & Sessler, D. I. (2013). The skilled nurses in pediatric patients waived. of obesity on success rates. assigned to VeinViewer vs. 62%
VeinViewer vascular imaging with anticipated difficult IV access. in patients assigned to routine
Methods: Patients aged 0 to Statistics: Cochran–Mantel–
system worsens first-attempt Also to look at effects of obesity on cannulation, with an adjusted
18 years were randomized to Haenszel Test, MV logistic
cannulation rate for experienced cannulation success. relative “risk” (95% CI), of 0.76
VeinViewer or traditional IV. All regression
nurses in infants and children with (0.63–0.91). The Z-statistic of −3.6
cannulations were performed by
anticipated difficult intravenous crossed the “harm” boundary
members of the Intravenous Access
access. Anesthesia and Analgesia, (Z < −2.41), with corresponding
Team.
116(5), 1087–1092. doi:10.1213/ p value of 0.0003. The trial was
ANE.0b013e31828a739e Sample: N = 600. 299 patients stopped on statistical grounds since
(49%) were randomly assigned to the harm boundary for the primary
the VeinViewer group, 301 (51%) to outcome was crossed. There was no
routine cannulation. association between first-attempt
Setting: Large urban pediatric success.
medical center Conclusion: The VeinViewer
worsened first-attempt IV
insertion success by skilled
nurses. Surprisingly, first-attempt
success for IV cannulation was not
worsened by obesity.
Weiner, S. G., Sarff, A. R., Essner, To determine if using US-guidance Design: Prospective, non-blinded, Used standardized data collection Findings: Significant difference 1 II
D. E., Shroff, S. D., Budhram, G. for difficult peripheral line 2-site pilot study. Primary nurse form, SAS, chi-squared to compare in MD help requested between
R., Switkowski, K. M., . . . Darvish insertion by ER RNs trained in in US technique for patients to be categorical demographic variables groups: 11/21 (52.5%) of standard
A H. (2013). Single-operator use of US decreases the need for eligible for study. and patient satisfaction, t-tests for cases and 7/29 (24.1%) of US
ultrasound-guided intravenous line physician intervention in placing between-group analysis. cases (p = 0.04). Mean time to
Sample: Convenience sample
placement by emergency nurses the line. Also investigated the IV placement not significantly
(n = 50) identified for inclusion
reduces the need for physician time to line placement, patient different between groups: US 27.6
by primary nurse. Inclusion
intervention in patients with satisfaction, and number of min (95% CI 16.0–39.1), standard
criteria: over 18 years, requiring
difficult-to-establish intravenous punctures when using the US vs. 26.4 min (95% CI 16.8–36.0) p
IV therapy as determined by
access. The Journal of Emergency standard of care. = 0.88. Number of punctures
MD, and either with a history of
Medicine, 44(3), 653–660. not significantly different: US
difficult IV access (self-report or
doi:10.1016/j.jemermed.2012.08.021 2.0 punctures (95% CI 1.5–2.4),
knowledge from RN/MD previous
standard 2.1 punctures (95% CI
experience with patient) or 2
1.6–2.6) p = 0.57. No significant
unsuccessful punctures by primary
difference in patient satisfaction
nurse. Excluded intoxicated, acute
between groups but US had higher
psychiatric patients, prisoners, or
“very satisfied” or “satisfied”
those unable to provide informed
(86.2%) than standard group
consent. IRB approved.
(63.2%), p = 0.06. No differences
Setting: EDs of 2 teaching in pain between groups (mean
hospitals, one urban and one with score from 0–10: US 4.9 (95% CI
a large rural population 3.6–6.1) and standard 5.5 (95% CI
4.1–6.9), p = 0.50.
33
GRADING THE QUALITY OF THE EVIDENCE

1. Acceptable Quality: No concerns
2. Limitations in Quality: Minor flaws or inconsistencies in the evidence
3. Major Limitations in Quality: Many flaws and inconsistencies in the evidence
4. Not Acceptable: Major flaws in the evidence
GRADING THE LEVELS OF THE EVIDENCE (MELNYK & FINEOUT-OVERHOLT, 2019)

I. Evidence from a systematic review or meta-analysis of all relevant, randomized, controlled trials
or evidence-based clinical practice guidelines based on systematic reviews of RCTs
II. Evidence obtained from at least one properly designed, randomized, controlled trial
III. Evidence obtained from well-designed controlled trials without randomization
IV. Evidence obtained from well-designed case control and cohort studies
V. Evidence from systematic reviews of descriptive and qualitative studies
VI. Evidence from a single descriptive or qualitative study
VII. Evidence from opinion of authorities and/or reports of expert committees
34
Appendix 2: Other Resources
Reference Description Conclusions

American College of Emergency Physicians. (2011). Alternative Policy statement from ACEP Alternative methods to difficult venous access must be available
methods to vascular access in emergency departments. and their usage should be part of the standard emergency medicine
Annals of Emergency Medicine, 58(4), 402. doi:10.1016/j. privileges. Alternative methods include intraosseous access, external
annemergmed.2011.07.015 jugular lines, and illumination. Policy and procedures should allow
for non-physician practitioners to establish access via alternate routes
when indicated. Policy should include training requirements.
Au, A. K., Rotte, M. J., Grzybowski, R. J., Ku, B. S., & Fields, J. Objective: To quantify reduction in CVC line placement through USGPIV placement resulted in a reduction in CVC line placement
M. (2012). Decrease in central venous catheter placement due to USGPIV placement. of 85%. The researchers concluded that USGPIV reduces the need
use of ultrasound guidance for peripheral intravenous catheters. for CVC line placement and may reduce the number of attempts in
The American Journal of Emergency Medicine, 30(9), 1950–1954. DIVA patients.
doi:10.1016/j.ajem.2012.04.016
Benson, G. (2015). Intraosseous access to the circulatory system: An Objective: To discuss the history, use, benefits, and contraindications Discusses history, benefits, and contraindications of IO use
under-appreciated option for rapid access. Journal of Perioperative of IO use.
Practice, 25(7–8), 140–143. doi:10.1177/1750458915025007-805
Butterfield, M., Abdelghani, R., Mohamad, M., Limsuwat, C., & Objective: To determine the feasibility of US-guided peripheral Used 2.5 in. 18-g catheter, 80% on 1st attempt, 20% on second
Kheir, F. (2017). Using ultrasound-guided peripheral catheterization IJ cannula insertion in patients with difficult IV access. attempt. Feasible to do in this small inpatient population with
of the internal jugular vein in patients with difficult peripheral access. difficult IV access.
American Journal of Therapeutics, 24(6), e667–e669. doi:10.1097/
MJT.0000000000000357
Chiao, F. B., Resta-Flarer, F., Lesser, J., Ng, J., Ganz, A., Pino-Luey, Objective: To determine if infrared technology will allow finding African-American or Asian ethnicity and obesity were associated
D., . . . Witek, B. (2013). Vein visualization: Patient characteristic more potential cannulation sites. Also, to identify characteristics with decreased vein visibility. The visibility of veins eligible for
factors and efficacy of a new infrared vein finder technology. British of DIV. cannulation increased for all subgroups using a new infrared device.
Journal of Anaesthesia, 110(6), 966–971. doi:10.1093/bja/aet003
Dillon, F. (2007). Concerns about the use of forced-air warming Letter to the editor The author warns of the potential for adverse effects of using forced
to facilitate intravenous cannulation: Don’t “hose” the patient. air to warm the extremity of a patient to facilitate IV cannulation.
Anesthesia & Analgesia, 104(3), 739–740. doi:10.1213/01. This off-label use of forced air warming known as "hosing" is
ane.0000253913.77092.9b potentially dangerous to patients.
Eldridge, D. L. (2010). Alternatives to intravenous rehydration in Review article Article describes difficult venous access in children including stress of
dehydrated pediatric patients with difficult venous access. Pediatric the procedure on patients, parents, and staff. Average of 2.35 attempts
Emergency Care, 26(7), 529–535. doi:10.1097/PEC.0b013e3181e5c00e to place an IV was required. 53% of IVs were successful on the first
attempt. Average time to place an IV was 20 minutes. Patient factors
related to difficult access including size of the patient, age, quality
of veins, history of prematurity, and poor vein visibility. Very brief
review of alternatives including SCRT, IO, NG, and oral rehydration.
Elia, F., Ferrari, G., Molino, P., Converso, M., De Filippi, G., Milan, Objective: To compare short catheter (SC) and long catheter (LC) Success rate was 86% in the SC groups and 84% in the LC group
A., & Aprà, F. (2012). Standard-length catheters vs long catheters in USG IV failure rates and determine if USG LC IV cannulations have (p = 0.77). Time to achieve venous access was shorter for SC than for
ultrasound-guided peripheral vein cannulation. The American Journal longer survival rates. LC (9.5 vs. 16.8 minutes, respectively; p = 0.001). Catheter failure was
of Emergency Medicine, 30(5),712–716. doi:10.1016/j.ajem.2011.04.019 observed in 45% of patients in the SC group and in 14% of patients
in the LC group (relative risk, 3.2; p < 0.001). Both SC and LC US-
guided cannulations had a high success rate in patients with difficult
venous access.
35

Fields, J. M., Todman, R. W., Anderson, K. L., Panebianco, N. L., & Objective: To determine the effect of vessel depth, diameter, and 11% failed within 4 hours and 24% failed within 12 hours. Vessel
Dean, A .J. (2010). Early failure of ultrasonography-guided peripheral location on early failure of US-guided PIV in the ED. depth was an independent predictor of early failure: odds ratio
intravenous catheters in the emergency department: It’s not just about 1.7 for each 0.2 cm increase in depth. 0% early failure for vessels
getting the IV - it’s about keeping it. Annals of Emergency Medicine, below 0.6 cm, 10% for vessels 0.6 to 0.99 cm, and 27% for vessels
56(3), S75–S76. doi:10.1016/j.annemergmed.2010.06.277 1 cm or greater. For overall US-guided IV placement, vessel depth
and location were both independent predictors. 34% failure rate when
placed in the arm compared to 7% failure when placed in or distal
to the antecubital fossa.
Fowler, R., Gallagher, J. V., Isaacs, S. M., Ossman, E., Pepe, P., Review article Review of intraosseous vascular access in the out-of-hospital
& Wayne, M. (2007). The role of intraosseous vascular access in arena. Reviews the types of IO available, insertion sites, training
the out-of-hospital environment (resource document to NAEMSP requirements, success rates, and limitations of treatment.
position statement). Prehospital Emergency Care, 11(1), 63–66.
doi:10.1080/10903120601021036
Kuensting, L. L. (2011). Subcutaneous infusion of fluid in children. Review article Provides an in-depth review of subcutaneous rehydration therapy
Journal of Emergency Nursing, 37(4), 346–349. doi:10.1016/j. (SCRT) including anatomy and physiology, site selection, actions of
jen.2010.05.005 hyaluronidase, and questions from a nursing and parent standpoint.
Kuensting, L. L., DeBoer, S., Holleran, R., Shultz, B. L., Steinmann, Review article Difficult venous access is prevalent in the pediatric population.
R. A., and Venella, J. J. (2009). Difficult venous access in children: Special techniques should be used to improve success rates.
Taking control. Journal of Emergency Nursing, 35(5), 419–424. If unsuccessful after 2–4 attempts, alternative methods should
doi:10.1016/j.jen.2009.01.014 be sought.
Langley, D. M., & Moran, M. (2008). Intraosseous needles: They're Case study Review of two adult cases where intraosseous was utilized. Includes
not just for kids anymore. Journal of Emergency Nursing, 34(4), indications for use, complications, and precautions.
318–319. doi:10.1016/j.jen.2007.07.005
Larsen, P., Eldridge, D., Brinkley, J., Newton, D., Goff, D., Primary objective: To describe the number of attempts and the time Difficult venous access is prevalent in the pediatric population.
Hartzog, T., . . . Perkin, R. (2010). Pediatric peripheral intravenous required for a general pediatric nurse to cannulate a peripheral IV in Special techniques should be used to improve success rates. If
access: Does nursing experience and competence really make a hospitalized children. unsuccessful after 2–4 attempts, alternative methods should
difference? Journal of Infusion Nursing, 33(4), 226–235. doi:10.1097/ be sought.
Secondary objective: To determine the amount of time and the number
NAN.0b013e3181e3a0a8
of venipuncture attempts to successfully cannulate a peripheral vein
as they relate to nurse and patient characteristics.
MacKinnon, K. A. (2009). Intraosseous vascular use at signature Review article History of intraosseous (IO) including physiology of the vascular
healthcare Brockton Hospital Department of Emergency Services. structure of the bone, indications for use, use of blood for laboratory
Journal of Emergency Nursing, 35(5), 425–428. doi:10.1016/j. testing, and removal. Protocol changes have resulted in IO being a
jen.2009.01.016 front-line consideration.
Mahler, S. A., Wang, H., Lester, C., & Conrad, S. A. (2008). Objective: To describe a novel technique of ultrasound-guided (US) Successful cannulation in 96% of the patients. Mean number of
Ultrasound-guided peripheral intravenous access in the emergency IV placement. The basilic vein was cannulated with dynamic guidance needle sticks was 1.32. Mean time from skin to catheter insertion was
department using modified Seldinger technique: A novel technique. by the high frequency linear ultrasound probe with transverse probe 86 seconds. Mean total procedure time was 524 seconds (8 minutes
Annals of Emergency Medicine, 52(4), S147. doi:10.1016/j. orientation. Seldinger technique was used to insert the cannula into 44 seconds). IVs were rechecked 1 hour after insertion, with 18/20
annemergmed.2008.06.372 the vein over a wire. still being patent. Mean score on satisfaction was 9.38 on a 1–10
Likert scale.
36

Miles, G., Salcedo, A., & Spear, D. (2012). Implementation of a Review article Provides a history of US-guided IV cannulation, how the program
successful registered nurse peripheral ultrasound-guided intravenous was implemented, and a discussion of key factors for success. In
catheter program in an emergency department. Journal of Emergency conclusion, US-guided IV cannulation increased patient satisfaction,
Nursing, 38(4), 353–356. doi:10.1016/j-jen.2011.02.011 decreased nurse/physician frustration, resulted in a cost and time
savings, and reduced complications related to a reduced number of
central lines.
Nafiu, O. O., Burke, C., Cowan, A., Tutuo, N., Maclean, S., & Objective: To evaluate relationship between BMI and ease of venous PIV cannulation was achieved on the first attempt in 55.2%, while
Tremper, K. K. (2010). Comparing peripheral venous access between access in children undergoing non-cardiac surgical procedures 39.6% of patients had 2–3 attempts before successful cannulation.
obese and normal weight children. Paediatric Anaesthesia, 20(2), Obese children were more likely to have a failed first attempt at
172–176. doi:10.1111/j.1460-9592.2009.03198.x cannulation than lean controls (p < 0.001). Obese children were
more likely to require two or more attempts at cannulation than
lean children (p < 0.001). The most successful site for obese children
after a failed attempt in the dorsum of the hand is the volar surface of
the wrist.
O’Connor, R. E. (2007). Intraosseous vascular access in the out- Position paper of the NAEMSP Position paper supporting the use of IO access in the out-of-hospital
of-hospital setting position statement of the National Association setting. Recommendation that EMS agencies provide at least one
of EMS Physicians. Prehospital Emergency Care, 11(1), 62. method of IO access for pediatric patients and should consider IO
doi:10.1080/10903120601020939 access for adult patients.
Panebianco, N. L., Fredette, J. M., Szyld, D., Sagalyn, E. B., Pines, J. Objective: To study pain and anxiety levels in patients with difficult Pain with US-guided IV (1 = almost no pain to 5 = extremely painful)
M., & Dean, A. J. (2008). Ultrasound-guided peripheral intravenous IV access who have US-guided IVs, and their preference for US- with successful IV in 3 attempts was 1.82 vs. 2.55 without successful
access: Patient pain, anxiety and preference. Annals of Emergency guided IVs. IV. Pain in IV access without US was 1.86 with successful IV vs. 2.6
Medicine, 52(4), S61. doi:10.1016/j.annemergmed.2008.06.127 without successful IV. Anxiety with US was 2.51 with successful IV
vs. 2.7 without success. 6.6% would not want US-guided IV placement
in the future. 92.7% of the IV placement failures would still want
US-guided IV placement in the future.
Rauch, D., Dowd, D., Eldridge, D., Mace, S., Schears, G., Review article summarizing recommendation of consensus panel for Early recognition of difficult venous access should motivate
& Yen, K. (2009). Peripheral difficult venous access in physicians. Endorsed by ACEP. caregivers to seek alternatives to PIV when feasible.
children. Clinical Pediatrics (Philadelphia), 48(9), 895–901.
doi:10.1177/0009922809335737
Reeves, T., Morrison, D., & Altmiller, G. (2017). A nurse-led Objective: To determine if implementing a VAPP with visualization The study found a 40% reduction in nonessential PICC insertions.
ultrasound-enhanced vascular access preservation program. The technology as opposed to using landmark techniques could reduce
15 participants had an 85% success rate with US-guided IV access
American Journal of Nursing, 117(2), 56–64. doi:10.1097/01. nonessential PICC utilization during a stay on the medical-surgical
with max of 2 attempts vs. 5.5 average attempts prior to intervention.
NAJ.0000527490.24610.51 and step-down units?
Riker, M. W., Kennedy, C., Winfrey, B. S., Yen, K., & Dowd, M. D. Objective: To validate and possibly refine Yen’s DIVA score rule. Study validated Yen’s DIVA score rule. Four variables were associated
(2011). Validation and refinement of the difficult intravenous access with failed IV placement: age, vein visibility, vein palpability, and
score: A clinical prediction rule for identifying children with difficult prior NICU stay. Three variables provided comparable outcomes to
intravenous access. Academic Emergency Medicine, 18(11), 1129– the four-variable rule: palpability, visibility, and age. Nurse confidence
1134. doi:10.1111/j.1553-2712.2011.01205.x level was the only nursing characteristic with statistically significant
findings. More confident nurses were less likely to have a failed
IV attempt.
37

Rouhani, S., Meloney, L., Ahn, R., Nelson, B. D., & Burke, T. F. Analysis of the effectiveness of non-oral and non-intravenous SCRT- 3 articles, 2 of which were from the 1960s. IO-1 RCT, 12
(2011). Alternative rehydration methods: A systematic review and methods of rehydration. Review of MEDLINE, Cochrane, Global case reports, 3 case series. The RCT (1994) compared IV to IO and
lessons for resource-limited care. Pediatrics, 127(3), e748–757. Health, Embase, and CINAHL databases for articles on intraosseous, found no difference in efficacy of rehydration or correction of lab
doi:10.1542/peds.2010-0952 nasogastric, intraperitoneal, subcutaneous, and rectal rehydration abnormalities between the two groups. IO placement was significantly
through December 2009. 38 articles; 3 on subcutaneous rehydration; faster and more reliable.
12 on NG rehydration; 7 on intraperitoneal rehydration; 16 on
intraosseous rehydration; none on proctoclysis. Patients less than 18
years of age. Included case reports and consensus-based guidelines.
Articles were not excluded based on quality of methods.
Sebbane, M., Claret, P. G., Lefebvre, S., Mercier, G., Rubenovitch, Objective: To investigate the relationship between BMI and PIV Peripheral lines were placed in 563 consecutive patients (53 ± 23
J., Jreige, R., ... de La Coussaye, J. E. (2013). Predicting peripheral access difficulty in an ED setting and identify patient-related years, BMI 26 ± 7 kg/m2), with a success rate of 98.6%, and a mean of
venous access difficulty in the emergency department using body predicting factors. 1.3 ± 0.7 attempts (range 1–7). Obese and underweight patients were
mass index and a clinical evaluation of venous accessibility. more likely than normal weight patients to have a failed IV attempt on
Journal of Emergency Medicine, 44(2), 299–305. doi:10.1016/j. first attempt.
Spandorfer, P. R. (2011). Subcutaneous rehydration: Updating a Review article First reports of hypodermoclysis or subcutaneous rehydration therapy
traditional technique. Pediatric Emergency Care, 27(3), 230–236. (SCRT) date back to 1913. Widespread use continued for both adults
doi:10.1097/PEC.0b013e31820e1405 and children until the 1950s when sporadic complications were
reported related to hypotonic fluid administration and inappropriate
volumes. An IV catheter is placed in the subcutaneous tissues; fluids
are absorbed into the vascular space. Advantages include ease of
administration.
Sturges, Z., White, S., Barton, E., Battaglia, D., & McCowan, C. Objective: To test the feasibility of EMTs using ultrasound (US) for US-guided group: Time to IV placement was 10.8 ± 6.15 minutes;
L. (2007). Ultrasound-guided peripheral intravenous access by the placement of peripheral IVs (PIV) for patients in the ED. 55.7% described as difficult access. First attempt success 93.4%,
emergency medical technicians. Annals of Emergency Medicine, second was 98.4%. Average 1.15 ± 0.48 PIV attempts. Satisfaction
50(3), S87–S88. doi:10.1016/j.annemergmed.2007.06.264 with the PIV access was 9 ± 1.74 (Likert scale of 1–10). Baseline
time to blind PIV placement is not addressed. 76.5% success on
first attempt, 88.2% within 2 attempts, 92.2% within 3 attempts.
Satisfaction on blind PIV attempt was 5.93 ± 2.87.
Voigt, J., Waltzman, M., & Lottenberg, L. (2012). Intraosseous Systematic review Findings: In levels 2 to 5 studies, IO access performed better versus
vascular access for in-hospital emergency use: A systematic clinical alternative access methods on the end points of time to access and
review of the literature and analysis. Pediatric Emergency Care, successful access. Complications appeared to be comparable to other
28(2), 185–199. doi:10.1097/PEC.0b013e3182449edc venous access methods. Randomized controlled trials are lacking.
Newer IO access technologies appear to do a better job of gaining
successful access more quickly. Intraosseous access is underutilized
in the ED because of a lack of awareness, guidelines/indications,
proper training, and proper equipment. Conclusions: Underutilization
exists despite recommendations for IO access use from a number
of important medical associations peripherally involved in the ED
such as the American Academy of Pediatrics. To encourage the
IO approach, IO product champions (as both supporter and user)
in the ED are needed for prioritizing and assigning IO access use
when warranted. In addition, specialty societies directly involved in
emergent hospital care should develop clinical guidelines for IO use.
38

Von Hoff, D. D., Kuhn, J. G., Burris, H. A., & Miller, L. J. (2008). Objective: To compare the pharmacokinetics of IO- vs. IV- Findings: No significant differences between the IV and IO routes on
Does intraossesous equal intravenous? A pharmacokinetic study. administered morphine sulfate. plasma morphine concentration vs. sampling time or pharmacokinetic
American Journal of Emergency Medicine, 26(1), 31–38. doi:10.1016/j. parameters.
ajem.2007.03.024
Conclusion: Routes are essentially equivalent. Statistically significant
difference in the volume of distribution in the central compartment
(p = 0.0247) thought to be due to deposition effect near the IO port or
in the bone marrow.
Wax, D. (2007). Difficult intravenous access: Second thoughts. Letter to the editor Practice of “hosing” (providing warmed air onto a concentrated
Anesthesia and Analgesia, 104(3), 739. doi:10.1213/01. extremity with a goal of dilating the vessels) has resulted in patient
ane.0000253915.99006.24 burns. This subject is addressed by the Food and Drug Administration
safety alert.
Weiser, G., Hoffmann, Y., Galbraith, R., & Shavit, I. (2012). Systematic review Findings: 179 studies identified; 10 met inclusion criteria. Most studies
Current advances in intraosseous infusion - a systematic review. have low level of evidence; a few studies on superiority of battery-
Methods: The electronic databases PubMed and Embase were
Resuscitation, 83(1), 20–26. doi:10.1016/j.resuscitation.2011.07.020 powered IO driver over SA IO devices.
searched for articles published from 1997 to 2010 using the search
terms (“intraosseous”) AND (“needle” or “device” or “technique”) Conclusions: Only a few studies compared the performance of
AND (“infusion” or “injection” or “access”). Google Scholar was different types of IO infusion devices; most of them have a low level
searched to identify articles published in electronic journals, books, of evidence. These studies suggested a superiority of the battery-
and scientific websites. Articles were included only if they compared powered IO driver over manual needles and other semi-automatic
at least two types of semi-automatic devices or compared one or more IO infusion devices.
semi-automatic device with one or more manual needles. Reviews,
editorials, surveys, and case reports were excluded.
White, A., Lopez, F., & Stone, P. (2010). Developing and sustaining Literature review Provides an overview of the benefits of US-guided peripheral
an ultrasound-guided peripheral intravenous access program for intravenous access and outlines the process used at Duke Medical
emergency nurses. Advanced Emergency Nursing Journal, 32(2), Center for training emergency nurses on the use of ultrasound-guided
173–188. doi:10.1097/TME.0b013e3181dbca70 venous cannulation.
White, S., Sturges, Z., Barton, E., Battaglia, D., & McCowan, Objective: To assess the feasibility of EMTs use of US-guided PIV Average time spent on IV access was 14.95 ± 7.45 minutes. 95.6%
C. L. (2007). Ultrasound-guided peripheral intravenous access placement for patients in the ED with difficult IV access. were considered difficult IV access. 22.2% had one blind IV attempt
by emergency medical technicians in patients with difficult prior to US; 24.4% had 2 attempts; 40% had 3 attempts; 13.3% had
access. Annals of Emergency Medicine, 50(3), S85. doi:10.1016/j. > 3 attempts. Success with US-guided PIV was 75.6% on first attempt;
annemergmed.2007.06.256 95.6% on second attempt. Average of 1.29 ± 0.56 attempts with US.
Patient satisfaction with US-guided was 8.9 ± 2.5 vs. 4.0 ± 2.5 for
blind IV attempt (1–10 Likert scale).
Witting, M. D. (2012). IV access difficulty: Incidence and delays in an Objective: To estimate the incidence of IV access difficulty and its In an urban ED, mild to moderate IV access difficulty was common
urban emergency department. Journal of Emergency Medicine, 42(4), associated delays in the ED. and led to minor delays; severe IVAD resulted in significant delays.
483–487. doi:10.1016/j.jemermed.2011.07.030
Yen, K., Riegert, A., & Gorelick, M. H. (2008). Derivation of the Objective: To develop a clinical prediction rule (DIVA Score) that A clinical prediction rule was created to apply as predictor of success
DIVA score: A clinical prediction rule for the identification of children would be easy to apply and be useful for predicting success or failure or failure of PIV access. Success rate of 75% at first attempt. Using
with difficult intravenous access. Pediatric Emergency Care, 24(3), of peripheral intravenous line insertion in children. DIVA score, patients with 4 or above were more than 50% likely to
143–147. doi:10.1097/PEC.0b013e3181666f32 have a failed IV at first attempt.
39
Appendix 3: Study Selection Flowchart and Inclusion/Exclusion Criteria
Potentially relevant publications identified

by electronic search
(n = 299)
Publications excluded as they did not meet
the PICOT question
(n = 232)
Publications reviewed in full text

(n = 67)

the PICOT question upon full review
(n = 8)
Publications reviewed in full

(n = 59)

evidence analysis criteria
(n = 13)
Publications that met criteria to be included in
evidence analysis (sound and relevant studies)
(n = 33)
Publications not excluded from evidence analysis,
but included as background information
(n = 13)
Inclusion Criteria Exclusion Criteria
Studies published in English Studies not published in English
Studies involving human subjects Non-human studies
October 2011–October 2018 Studies not in the timeframe listed
Studies addressing the PICOT question Studies not addressing the PICOT questions
The following databases were searched: PubMed, Google Scholar, CINAHL, Cochrane - British Medical Journal,
Agency for Healthcare Research and Quality, and the National Guideline Clearinghouse.
Search terms included: “difficult intravenous access”, “tools intravenous access”, “heat”, “nitroglycerin”,
“tourniquet”, “ultrasound”, “light”, “illumination”, “subcutaneous rehydration therapy”, and “hypodermoclysis”,
“interosseous”, “infrared”, and “ultrasound guided” using a variety of different search combinations
40
Synopsis Difficult Intravenous Access
CLINICAL QUESTION:
In ED patients requiring vascular access, which alternative techniques improve outcomes compared with traditional IV insertion?
PROBLEM:
Establishing vascular access is one of the most common procedures carried out in the emergency department (ED) and is a high
priority for the care of critically ill and unstable patients. The patient’s condition often plays a role in the likelihood of attaining
vascular access. Difficult intravenous access is defined as requiring multiple attempts and/or the anticipation of needing special
interventions to establish and maintain peripheral venous access (Kuensting, DeBoer, Holleran, Shultz, Steinmann, & Venella,
2009). Conditions associated with difficult vascular access include obesity, chronic illness, hypovolemia, intravenous (IV) drug
abuse, and vasculopathy (Blaivas & Lyon, 2006; Chinnock, Thornton, & Hendey, 2007; Costantino, Parikh, Satz, & Fojtik, 2005;
Doniger, Ishimine, Fox, & Kanegaye, 2009; Heinrichs, Fritze, Vandermeer, Klassen, & Curtis, 2013; Miles, Salcedo, & Spear, 2012;
Nafiu et al.,2010; Sebbane et al., 2013). Additionally, age may be a factor in successful cannulation: in children under the age of two
years, particularly young infants, intravenous access is more likely to be difficult to obtain (Chapman, Sullivan, Pacheco, Draleau, &
Becker, 2011; Heinrichs, Fritze, Vandermeer, Klassen, & Curtis 2013) as there is often a lack of a palpable and visible vein (Nafiu et
al., 2010; Yen, Reigert, & Gorelick, 2008).

Conclusions and recommendations about alternatives to venous access in the patient with difficult IV access in the ED:
Adults
Ultrasound-guided access should be considered for adult patients with difficult access who have had unsuccessful PIV attempts
using traditional methods. (Bahl et al., 2016; Egan et al., 2013; Heinrichs et al., 2013; Liu et al., 2014; McCarthy et al., 2016; A
Scoppettuolo et al., 2016; Stolz et al., 2015)
Ultrasound- Ultrasound-guided IV access is a technique that can effectively be performed by physicians, nurses, and ED technicians. (Bahl et al.,
Guided 2016; Bauman et al., 2009; Blaivas & Lyon, 2006; Brannam et al., 2004; Chinnock et al., 2007; Costantino et al., 2005; Panebianco et A
Intravenous al., 2009; Schoenfeld et al., 2011; Scoppettuolo et al., 2016; Stein et al., 2009; Weiner et al., 2013)
Access
Ultrasound-guided IV insertion may not decrease patients’ pain level on insertion. (McCarthy et al., 2016; Stein et al., 2009; Weiner
B
et al., 2013)
Ultrasound-guided techniques may result in improved patient satisfaction. (Bauman et al., 2009; Costantino et al., 2005) C
Intraosseous access is an alternative to intravenous access and is effective for the administration of blood and blood products,
fluid administration, drug delivery, and blood sampling. (Burgert, 2009; Leidel et al., 2012; Leidel et al., 2009; Paxton et al., 2009; A
Intraosseous Petitpas et al., 2016; Phillips et al., 2010)
Vascular
Access In alert patients, pain with intraosseous needle insertion is rated as minor. (Paxton et al., 2009) C
Intraosseous lidocaine administration prior to medication infusion reduces the pain felt by alert patients. (Paxton et al., 2009) C
Subcutaneous
SCRT is an alternative to peripheral IV insertion for mildly to moderately dehydrated older adult patients when oral rehydration
Rehydration B
efforts have been unsuccessful. (Forbat et al., 2017; Remington & Hultman, 2007; Slesak, et al., 2003)
Therapy
Controlled warming to facilitate IV cannulation is a therapeutic option that can be used to improve cannulation success rate
Warming C
in a timely manner. (Fink et al., 2009; Lenhardt et al., 2002)
© Emergency Nurses Association, 2019.

Synopsis Difficult Intravenous Access
Pediatrics
Ultrasound-
Guided There is insufficient evidence to make recommendations regarding the benefits of ultrasound-guided IV insertion in the
I/E
Intravenous pediatric population.
Access
Intraosseous
There is insufficient evidence to make recommendations regarding which IO insertion device is the most successful in the
Vascular I/E
pediatric population.
Access
Subcutaneous
SCRT is an alternative to peripheral IV insertion for the mildly to moderately dehydrated pediatric patient when oral rehydration
Rehydration C
efforts have been unsuccessful. (Allen, et al., 2009; Kuensting, 2013; Spandorfer et al., 2012)
Therapy
EMLA and The use of EMLA or vapocoolants may increase the success rate for IV access in pediatric patients. (Huff et al., 2009; Schreiber et
C
Vapocoolants al., 2018)
The use of alternative devices does not improve the IV start success rate or time to cannulation in pediatric patients. (Chapman et al.,
Alternative
2011; Curtis et al., 2015; Katsogridakis et al., 2008; McNeeley et al., 2018; Perry et al., 2011; Rothbart et al., 2015; Simhi, Kachko, A
Devices
Bruckheimer, & Katz, 2008; Szmuk et al., 2013)
Level A (High) Based on consistent and good quality of evidence; has relevance and applicability to emergency nursing practice.
Level B (Moderate): There are some minor inconsistencies in quality evidence; has relevance and applicability to emergency nursing practice.
Level C (Weak) There is limited or low-quality patient-oriented evidence; has relevance and applicability to emergency nursing practice.
N/R Not Recommended Based upon current evidence.
I/E: Insufficient evidence upon which to make a recommendation.
N/E: No evidence upon which to make a recommendation.
Access the full clinical guideline at: https://www.ena.org/docs/default-source/resource-library/practice-resources/cpg/

difficultivaccesscpg.pdf
ENA Clinical Practice Guidelines (CPGs) are evidence-based documents that facilitate the application of current evidence into
everyday emergency nursing practice. CPGs contain recommendations based on a systematic review and critical analysis of
the literature about a clinical question. CPGs are created following the rigorous process described in ENA’s CPG Development
Manual. The purpose of CPGs is to positively impact patient care in emergency nursing by bridging the gap between practice
and currently available evidence.
© Emergency Nurses Association, 2019.

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Clinical Practice Guideline:

Difficult Intravenous Access

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Background and Significance

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Table 1. Levels of Recommendation for Practice

• Reflects a high degree of clinical certainty

Level B Recommendations: Moderate

• Reflects moderate clinical certainty

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Summary of Literature Review

DIFFICULT INTRAVENOUS ACCESS IN ADULTS

Successful Cannulation with Ultrasound Guidance

930 E. Woodfield Road, Schaumburg, IL 60173 | 800.900.9659 | www.ena.org | Follow us

Patient Satisfaction and Pain

Intraosseous Vascular Access

930 E. Woodfield Road, Schaumburg, IL 60173 | 800.900.9659 | www.ena.org | Follow us

Success Rate on First Attempt

Patient Report of Pain on Insertion and Infusion

Subcutaneous Rehydration Therapy

930 E. Woodfield Road, Schaumburg, IL 60173 | 800.900.9659 | www.ena.org | Follow us

DIFFICULT INTRAVENOUS ACCESS IN PEDIATRICS

930 E. Woodfield Road, Schaumburg, IL 60173 | 800.900.9659 | www.ena.org | Follow us

Successful Cannulation with Ultrasound Guidance

Subcutaneous Rehydration Therapy

930 E. Woodfield Road, Schaumburg, IL 60173 | 800.900.9659 | www.ena.org | Follow us

EMLA CreamTM and Vapocoolants

930 E. Woodfield Road, Schaumburg, IL 60173 | 800.900.9659 | www.ena.org | Follow us

Description of Decision Options/Interventions and the Level of Recommendation

Description of Decision Options/Interventions and the Level of Recommendation

930 E. Woodfield Road, Schaumburg, IL 60173 | 800.900.9659 | www.ena.org | Follow us

Description of Decision Options/Interventions and the Level of Recommendation

930 E. Woodfield Road, Schaumburg, IL 60173 | 800.900.9659 | www.ena.org | Follow us

930 E. Woodfield Road, Schaumburg, IL 60173 | 800.900.9659 | www.ena.org | Follow us

930 E. Woodfield Road, Schaumburg, IL 60173 | 800.900.9659 | www.ena.org | Follow us

930 E. Woodfield Road, Schaumburg, IL 60173 | 800.900.9659 | www.ena.org | Follow us

ENA 2018 Board of Directors Liaison: Gordon Gillespie, PhD, RN

Developed: December 2011

930 E. Woodfield Road, Schaumburg, IL 60173 | 800.900.9659 | www.ena.org | Follow us

Research/Purpose Quality of Level of

Research/Purpose Quality of Level of

Research/Purpose Quality of Level of

Research/Purpose Quality of Level of

Research/Purpose Quality of Level of

Research/Purpose Quality of Level of

Research/Purpose Quality of Level of

Research/Purpose Quality of Level of

Research/Purpose Quality of Level of

Research/Purpose Quality of Level of

Research/Purpose Quality of Level of

Research/Purpose Quality of Level of

Research/Purpose Quality of Level of

Research/Purpose Quality of Level of

Research/Purpose Quality of Level of

Research/Purpose Quality of Level of

Research/Purpose Quality of Level of

GRADING THE QUALITY OF THE EVIDENCE

GRADING THE LEVELS OF THE EVIDENCE (MELNYK & FINEOUT-OVERHOLT, 2019)

Reference Description Conclusions

Reference Description Conclusions

Reference Description Conclusions

Reference Description Conclusions