Ultrasound vs Veinviewer in Patients With Difficulty IV Access

Intravenous (IV) access is important for patient care in emergency medicine as an estimate of
78% of ED patients would require more than 3 ED resources such as blood tests, medication,
contrast, fluid. Care for patients with difficult intravenous access (DIVA) could be
significantly delayed as it may take up to 120 minutes to establish IV access in patients
with severe DIVA. Many solutions for DIVA had also been established to avoid central venous
catheter insertion, including using ultrasound or near-infrared imaging systems for
peripheral IV insertion.

Using ultrasound in the ED has been shown to decrease the rate of central venous catheters
(CVC) insertion. However, the results from ultrasound-guided peripheral IV insertion (USGPIV)
have been mixed. Among patients with DIVA, Costantino reported USGPIV required less time to
successful first cannulation and fewer punctures comparing to traditional approach of
landmark and palpation. However, other studies showed that USGPIV did not improve successful
first attempts comparing to traditional IV insertion, and may have taken same or even longer
time to successfully establish IV. USGPIV success rate requires more training for nurses and
ED technicians as it is operator - dependent.

Patients have difficulty with IV access because their veins' clinical accessibility is low,
for example, they are less visible or less palpable. The near-infrared imaging devices, such
as Christie Digital's VeinViewer, improve this situation by using infra-red lights to make
veins visible to the eyes.

Compared with routine IV insertion, near-Infra red imaging devices have been shown to
increase first successful attempts and in less time in children with DIVA and improved
visualization of peripheral veins. However, it did not show higher rate of successful
attempts nor faster time in non-selected adults.

The efficacy of these near-infrared devices has not been established among adult patients
with DIVA.

Inclusion Criteria:

- Patients who fail inspections for visible or palpable veins or

- Patients who request Ultrasound guided peripheral IV (USGPIV)

- patients who are oriented to self (correct last name, first name), place (correct name
of hospital), time (correct day of week or month of year) and person (correct name of
current president)

Exclusion Criteria:

- Patients < 18 years of age

- Patients with hemodynamically instability requiring rapid central access.

- Patients with impaired cognition and not able to consent, these patients are :

- Clinically intoxicated patients, as defined by primary team.

- Patients who family reported as "confused", "confusion", "altered mental status."

- Patients who is not oriented x 4 as above

- Patients who do not speak English.