title: Advanced intravenous access: technique choices, pain scores, and failure rates in a local registry.
abstract: BACKGROUND
  When an intravenous (IV) catheter is needed and the common approach of inspection and palpation fails, an advanced access technique becomes necessary. Our objectives were to estimate pain scores, operator times, success rates, and complication rates when advanced techniques are used in a clinical setting.
  
  
  METHODS
  We enrolled patients who had a need for advanced IV access and were able to give informed consent to participate in our study. We collected data on operator type, technique, initial success, number of attempts, skin punctures, operator time, pain scores, and complications. We estimated confidence intervals for proportions using normal binomial approximation or exact calculation.
  
  
  RESULTS
  The registry documented 154 attempts in 116 patients. The median time from triage to establishment of an IV line was 203 minutes; multiple advanced attempts were required in 24% of cases. Most attempts (95%) used either ultrasound-guided cannulation of a peripheral vein (PUG) (108) or cannulated the external jugular vein (EJ) (38). These 2 methods yielded similar pain scores (4.3-4.5), but PUG required more skin punctures (1.6 vs 1.2) and longer operator time (17.7 vs 11.9 minutes). The only complication was IV line failure, occurring in 6% (95% confidence interval, 0%-18%) of EJ approaches and 27% (95% confidence interval, 18%-38%) of the PUG scenarios.
  
  
  CONCLUSIONS
  Most attempts to establish IV access used PUG or the EJ. External jugular vein cannulation was achieved more quickly, with fewer skin punctures and a lower rate of postinsertion failure, than PUG.
authors.affiliation: University of Maryland School of Medicine, Baltimore, MD. Electronic address: mwitting@em.umaryland.edu.
authors.forename: Michael D
authors.initials: MD
authors.lastname: Witting
authors.affiliation: University of Maryland School of Medicine, Baltimore, MD.
authors.forename: Siamak
authors.initials: S
authors.lastname: Moayedi
authors.affiliation: University of Maryland School of Medicine, Baltimore, MD.
authors.forename: Zhaoxin
authors.initials: Z
authors.lastname: Yang
authors.affiliation: University of Maryland Medical Center, Baltimore, MD.
authors.forename: Cheryll B
authors.initials: CB
authors.lastname: Mack
mesh_terms: D002404:Catheterization / Q000009:adverse effects / Q000379:methods* / Q000706:statistics & numerical data; D002405:Catheterization, Central Venous / Q000009:adverse effects / Q000379:methods / Q000706:statistics & numerical data; D002406:Catheterization, Peripheral / Q000009:adverse effects / Q000379:methods / Q000706:statistics & numerical data; D006801:Humans; D007601:Jugular Veins / Q000000981:diagnostic imaging; D017063:Outcome Assessment, Health Care / Q000706:statistics & numerical data; D010146:Pain / Q000209:etiology*; D011446:Prospective Studies; D012042:Registries; D018084:Ultrasonography, Interventional / Q000379:methods*