Unlocking Common ED Procedures: Approach to the Patient with Difficult Vascular Access

Authors: Richard J. Cunningham, MD (@HappyDays_EM, EM Resident Physician, Creighton/Maricopa Emergency Medicine Residency, Phoenix, AZ) and Geoffrey Comp, DO (@gbcomp, EM Attending, Creighton/Maricopa Emergency Medicine Residency, Phoenix, AZ) // Reviewed by: Anthony DeVivo, DO (EM-Critical Care Fellow, Icahn School of Medicine at Mount Sinai Hospital); Alex Koyfman, MD (@EMHighAK); Brit Long, MD (@long_brit)


A 36-year-old patient with a history of IV drug use presents with fever. After your history and physical, you order a chest x-ray and blood work including blood cultures. A few minutes later, your nurse calls to inform you she was unsuccessful at collecting the labs. Right after you hang up the phone, EMS wheels in a patient in cardiac arrest: A 67-year-old with history of end stage renal disease on dialysis, PEA on the monitor. Multiple IV attempts were unsuccessful in the field.

What would be your approach to obtaining access in these cases? Would it differ between the former and the latter?


Obtaining peripheral intravascular (IV) access is a common procedure in the Emergency Department and an essential aspect of managing critically ill patients. Each year, approximately 150 million PIVs are placed in the United States, up to 30% of which are in patients with difficult vascular access (DVA).1 Factors associated with DVA include obesity, diabetes, and IV drug use, among others. While some of these patients may ultimately require central venous catheter placement, any astute emergency physician should have a few tricks up his or her sleeve to obtain initial vascular access and avoid the time and associated risks of this invasive procedure.

The Crashing Patient

While a “crash” femoral central line is always a tempting option during a resuscitation, it is important to note that large bore peripheral IVs (14-16 gauge) achieve flow rates significantly higher than that of triple lumen central venous catheters (TLC), as evidenced in the table below. It’s also prudent to note that flow rate through any catheter is significantly increased with the addition of pressure-bags.2

In general, any critical patient should receive two sites of peripheral access in case one line fails. If peripheral IVs are not easily obtainable, one should strongly consider the placement of an intraosseous (IO) catheter in any patient presenting in extremis.

On average, IO catheters can be placed successfully in about 4 seconds.3 During cardiac arrest, IO placement has higher success rates and faster placement than central lines.4,5 Any fluid, blood product, or medication that can be infused through an IV catheter can also be infused through an IO. While typical infusion rates through an IO only approximate that through the distal port of a TLC, using a pressure-bag system can significantly increase flow:3

Blood samples can also be drawn for lab analysis from an IO. Hemoglobin, glucose, BUN, creatinine, chloride, CO2, total protein and albumin levels all correlate well between IO and IV samples, while white blood cell count and platelet levels as well as sodium, potassium, and calcium concentrations do not.6

While placement of the IO itself is generally well-tolerated, the process of medication and fluid administration is notably painful. Keep this in mind if you decide to use this device to gain access is any patient that is not obtunded or in cardiac arrest. In awake patients, infusing lidocaine prior to fluid or other drug administration can significantly decrease pain from infusion. The procedure for doing so is as follows:7

  1. Slowly infuse initial dose (adults 40 mg [2 ml of 2% lidocaine], children 0.5 mg/kg up to 40 mg over 120 seconds and allow to dwell for 60 seconds)
  2. Flush IO with ~5 ml of normal saline
  3. Consider infusing more lidocaine (half of initial dose) over 60 seconds
  4. Infuse fluids/medications as indicated, repeat prior procedure as needed

The Stable Patient

There are several other options to consider for vascular access in the stable patient. Each is described below. Since you usually have time to consider the differential and future needs for these patients, keep in mind that most facilities require lower gauge catheters (18-20 gauge or lower) and proximal (antecubital fossa or above) IVs for contrast-enhanced CT studies. Image quality is directly affected by flow rate through catheters, and adequate flow rates are far less likely to be achieved in smaller bore catheters in veins distal to the antecubital fossa.8, 9

Back to the Basics: Landmark-Based Technique

While typically performed by various healthcare professionals, landmark-based PIV placement is a skill with which every emergency physician should have some familiarity. While some would think a discussion of patients with DVA would preclude landmark-based techniques, one study found that of patients reporting requiring “multiple IV attempts” in the past, only 14% required more than three attempts or a rescue technique (ultrasound-guided IV or external jugular vein IV).10 Prior to attempting PIV insertion, see if your ancillary staff had tried a smaller gauge needle. Gentle fluid hydration and many medications can be administered through a 22-gauge catheter, so a patient with multiple failed attempts at cannulation with an 18 or 20-gauge needle can often be rescued by switching to a smaller bore catheter.

Several adjuncts meant to increase vein diameter can be used to increase the chance of success if nursing or EMS have difficulty (several of these adjuncts also apply to the US-guided technique):

  1. Use gravity to your advantage by placing the target vessel below the level of the heart
  2. Apply a tourniquet
  3. Have the patient “pump” their fist by clenching and relaxing it11
  4. Light tapping of the vein can induce venodilation via an unknown mechanism12
  5. “Milking” the vein proximal to distal can increase vein diameter13
  6. Application of warmth increases venodilation, decreases time to cannulation, and increases first pass success14
  7. If no heat packs are available, placing the patient’s hand in a disposable glove might do the trick15
  8. Several studies have shown application of nitroglycerin ointment to increase vein diameter and lead to increased successful placement 16, 17

A Forgotten Vein: The EJ

Once landmark-based attempts have been unsuccessful, before reaching for an ultrasound, consider the oft-neglected external jugular vein. Place the patient in Trendelenburg position and have them rotate their head away from the target vessel. While standing at the head of the bed, use your left thumb to provide traction and your index finger to compress the vein proximally. Cannulate midway between the angle of the jaw and the clavicle. Having the patient perform a Valsalva maneuver can also further distend the vessel.

The EM Staple: The Ultrasound-Guided IV

An excellent discussion of this technique can be found here. Ultrasound-guided IV placement has been shown to be highly successful, however failure rates can be as high as 45-56%, compared to 19-25% of landmark-placed IVs.18-22  Keeping that in mind, here are a few pointers to maximize success and longevity of the IV:

  1. Always start distally and work your way proximally until you find an adequate vessel
  2. Look for veins that are superficial and wide; one study demonstrated an odds ratio of 1.79 for increased successful cannulation with each 1 mm increase in vessel diameter, and no vessels were successfully cannulated beyond a depth of 1.6 cm23
  3. Utilize a longer catheter (ideally > 2.5 inches) to increase the lifespan of the IV24
  4. Failure of the IV is high when <30% of the catheter length is in the vessel and minimized when >65% of the catheter is intravascular25
  5. After obtaining the “flash” upon entry into the vessel, try to advance the needle as far into the vessel as possible before advancing the catheter over the needle
  6. While advancing the needle in the vein, maintain your probe position at the tip in order to avoid “back-walling” through the vessel, increasing the risk of extravasation and catheter failure

One final note: while there is limited evidence that probe covers and adhesive barriers limit infection,26 the American College of Emergency Physicians recommends the use of such barriers,27 and compliance with such recommendations is as low as 22% in one study.28

New Kid on the Block: The “Easy IJ”

When traditional landmark-based techniques, EJV cannulation, and ultrasound-guidance have failed, options are limited. In an otherwise stable patient, CVC placement would be the next option. However, a relatively new technique requires much less time, resources, and risk to the patient. The “Easy IJ” involves placing an extra-long 18-gauge single-lumen catheter (those typically used for US-guided IVs) in the internal jugular vein. In one study in the emergency setting among patients who had failed traditional ultrasound-guided PIV placement, this technique was successful 88% of the time. There was no incidence of line infection, arterial puncture, or pneumothorax, and the only complication was loss of catheter patency in 14% of patients.29 Insertion time was approximately 5 minutes on average, compared to 20 minutes for a central line according to one ED study.30 These lines were placed using the same level of sterile technique as ultrasound-guided peripheral IVs, therefore saving time and resources as compared to CVC placement. It should be noted that this study recommended a 24-hour limit on use of the line given concern for infection since it was placed in a central vein.

One Last Point

Some centers now utilize midline catheters as an alternative to placing ultrasound-guided IVs and even central lines. One observational study of 403 ED patients showed this technique to be successful 99% of the time with a median number of 1 attempt. Severe complications only occurred in 3 patients (1 arterial puncture and 2 vesicant extravasations) and no line-associated bloodstream infections or deep vein thromboses were observed. Vasopressors were also safely administered through these lines in 29.5% of patients.31

Micropuncture kits have revolutionized all forms of vascular access. For more details on this new technique check out this post.

Key Points

  1. When a patient is in extremis and PIVs are not easily obtainable, don’t hesitate to place an IO
  2. Utilize a pressure bag with any form of intravascular access to increase flow rates
  3. Blood aspirated from an IO can be used for laboratory analysis, although not all values will be accurate
  4. If using the landmark-approach, use adjunctive techniques to increase rates of success
  5. Consider the external jugular vein before jumping to ultrasound-guided PIV
  6. When placing an ultrasound guided IV, vessels that are more superficial and wider in diameter will lead to increased successful placement
  7. Longer catheters with the majority of the catheter in the vessel lead to increased lifespan of ultrasound-guided IVs
  8. If ultrasound-guided peripheral IV placement isn’t successful, consider an “easy-IJ” before placing a CVC
  9. Midline catheter placement is an emerging alternative to both ultrasound-guided IVs and CVCs

References/Further Reading

  1. Bahl A, Hang B, Brackney A, et al. Standard long IV catheters versus extended dwell catheters: A randomized comparison of ultrasound-guided catheter survival. Am J Emerg Med. 2019;37(4):715-721. doi:10.1016/j.ajem.2018.07.031
  2. Reddick AD, Ronald J, Morrison WG. Intravenous fluid resuscitation: was Poiseuille right? Emerg Med J. 2011;28(3):201-202. doi:10.1136/emj.2009.083485
  3. Ngo AS, Oh JJ, Chen Y, Yong D, Ong ME. Intraosseous vascular access in adults using the EZ-IO in an emergency department. Int J Emerg Med. 2009 Aug 11;2(3):155-60. doi: 10.1007/s12245-009-0116-9. PMID: 20157465; PMCID: PMC2760700.
  4. Leidel BA, Kirchhoff C, Bogner V, Braunstein V, Biberthaler P, Kanz KG. Comparison of intraosseous versus central venous vascular access in adults under resuscitation in the emergency department with inaccessible peripheral veins. Resuscitation. 2012;83(1):40-45. doi:10.1016/j.resuscitation.2011.08.017
  5. Lee PM, Lee C, Rattner P, Wu X, Gershengorn H, Acquah S. Intraosseous versus central venous catheter utilization and performance during inpatient medical emergencies. Crit Care Med. 2015;43(6):1233-1238. doi:10.1097/CCM.0000000000000942
  6. Miller LJ, Philbeck TE, Montez D, Spadaccini CJ. A new study of intraosseous blood for laboratory analysis. Arch Pathol Lab Med. 2010;134(9):1253-1260. doi:10.1043/2009-0381-OA.1
  7. Philbeck TE, Miller LJ, Montez D, Puga T. Hurts so good. Easing IO pain and pressure. JEMS. 2010;35(9):58-69. doi:10.1016/S0197-2510(10)70232-1
  8. Johnson PT, Christensen G, Lai H, Eng J, Fishman EK. Catheter insertion for intravenous (IV) contrast infusion in multidetector-row computed tomography (MDCT): defining how catheter caliber selection affects procedure of catheter insertion, IV contrast infusion rate, complication rate, and MDCT image quality. J Comput Assist Tomogr. 2014;38(2):281-284. doi:10.1097/01.rct.0000445640.20743.73
  9. Wienbeck S, Fischbach R, Kloska SP, et al. Prospective study of access site complications of automated contrast injection with peripheral venous access in MDCT. AJR 2010; 195:825–829
  10. Fields JM, Piela NE, Au AK, Ku BS. Risk factors associated with difficult venous access in adult ED patients. Am J Emerg Med. 2014;32(10):1179-1182. doi:10.1016/j.ajem.2014.07.008
  11. Simons P, Coleridge Smith P, Lees WR, McGrouther DA. Venous pumps of the hand. Their clinical importance. J Hand Surg Br. 1996;21(5):595-599. doi:10.1016/s0266-7681(96)80137-9
  12. Mbamalu D, Banerjee A. Methods of obtaining peripheral venous access in difficult situations. Postgrad Med J. 1999;75(886):459-462. doi:10.1136/pgmj.75.886.459
  13. Roberge RJ. Venodilatation techniques to enhance venipuncture and intravenous cannulation. J Emerg Med. 2004;27(1):69-73. doi:10.1016/j.jemermed.2004.02.011
  14. Lenhardt R, Seybold T, Kimberger O, Stoiser B, Sessler DI. Local warming and insertion of peripheral venous cannulas: single blinded prospective randomised controlled trial and single blinded randomised crossover trial. BMJ. 2002;325(7361):409-410. doi:10.1136/bmj.325.7361.409
  15. Ray P, Ray A. A novel approach to facilitate peripheral venous access. Postgrad Med J. 2018;94(1116):606-607. doi:10.1136/postgradmedj-2018-135858
  16. Hecker JF, Lewis GB, Stanley H. Nitroglycerine ointment as an aid to venipuncture. Lancet. 1983;1(8320):332-333. doi:10.1016/s0140-6736(83)91631-8
  17. Roberge RJ, Kelly M, Evans TC, Hobbs E, Sayre M, Cottington E. Facilitated intravenous access through local application of nitroglycerin ointment. Ann Emerg Med. 1987;16(5):546-549. doi:10.1016/s0196-0644(87)80682-0
  18. Bregenzer T, Conen D, Sakmann P, Widmer AF. Is routine replacement of peripheral intravenous catheters necessary? Arch Intern Med. 1998;158(2):151-156. doi:10.1001/archinte.158.2.151
  19. Catney MR, Hillis S, Wakefield B, et al. Relationship between peripheral intravenous catheter Dwell time and the development of phlebitis and infiltration. J Infus Nurs. 2001;24(5):332-341. doi:10.1097/00129804-200109000-00008
  20. Dargin JM, Rebholz CM, Lowenstein RA, Mitchell PM, Feldman JA. Ultrasonography-guided peripheral intravenous catheter survival in ED patients with difficult access. Am J Emerg Med. 2010;28(1):1-7. doi:10.1016/j.ajem.2008.09.001
  21. Elia F, Ferrari G, Molino P, et al. Standard-length catheters vs long catheters in ultrasound-guided peripheral vein cannulation. Am J Emerg Med. 2012;30(5):712-716. doi:10.1016/j.ajem.2011.04.019
  22. Soifer NE, Borzak S, Edlin BR, Weinstein RA. Prevention of peripheral venous catheter complications with an intravenous therapy team: a randomized controlled trial. Arch Intern Med. 1998;158(5):473-477. doi:10.1001/archinte.158.5.473
  23. Panebianco NL, Fredette JM, Szyld D, Sagalyn EB, Pines JM, Dean AJ. What you see (sonographically) is what you get: vein and patient characteristics associated with successful ultrasound-guided peripheral intravenous placement in patients with difficult access. Acad Emerg Med. 2009;16(12):1298-1303. doi:10.1111/j.1553-2712.2009.00520.x
  24. Bahl A, Hijazi M, Chen NW, Lachapelle-Clavette L, Price J. Ultralong Versus Standard Long Peripheral Intravenous Catheters: A Randomized Controlled Trial of Ultrasonographically Guided Catheter Survival. Ann Emerg Med. 2020;76(2):134-142. doi:10.1016/j.annemergmed.2019.11.013
  25. Pandurangadu AV, Tucker J, Brackney AR, Bahl A. Ultrasound-guided intravenous catheter survival impacted by amount of catheter residing in the vein. Emerg Med J. 2018;35(9):550-555. doi:10.1136/emermed-2017-206803
  26. Gottlieb M, Sundaram T, Holladay D, Nakitende D. Ultrasound-Guided Peripheral Intravenous Line Placement: A Narrative Review of Evidence-based Best Practices. West J Emerg Med. 2017;18(6):1047-1054.
  27. Guideline for Ultrasound Transducer Cleaning and Disinfection. American College of Emergency Physicians. https://www.acep.org/globalassets/new-pdfs/policy-statements/guideline-for-ultrasound-transducer-cleaning-and-disinfection.pdf. Published June 2018. Accessed December 22nd, 2020.
  28. Carrico R, Furmanek S, English C. Ultrasound probe use and reprocessing: Results from a national survey among U.S. infection preventionists. Am J Infect Control. 2018;46(8):913-920.
  29. Moayedi S, Witting M, Pirotte M. Safety and Efficacy of the “Easy Internal Jugular (IJ)”: An Approach to Difficult Intravenous Access. J Emerg Med. 2016;51(6):636-642. doi:10.1016/j.jemermed.2016.07.001
  30. Witting MD, Moayedi S, Yang Z, Mack CB. Advanced intravenous access: technique choices, pain scores, and failure rates in a local registry. Am J Emerg Med 2016;34:553–7.
  31. Spiegel RJ, Eraso D, Leibner E, Thode H, Morley EJ, Weingart S. The Utility of Midline Intravenous Catheters in Critically Ill Emergency Department Patients. Ann Emerg Med. 2020;75(4):538-545. doi:10.1016/j.annemergmed.2019.09.018


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