Comparison of Traditional and Ultrasound-Guided Techniques for Vascular Access in Patients With Difficult Venous Access in Emergency Department: Randomized Clinical Trial Protocol

Introduction It is estimated that 90% of patients attending Emergency Departments (ED) require venipuncture, with short peripheral intravenous catheters (PIVC) being the most used invasive devices in healthcare settings. However, there are patients for whom even experienced nurses require more than two attempts to successfully perform the procedure; these patients are classified as having difficult venous access (DIVA). This condition is estimated to occur in 10-24% of adult patients and up to 37% of children. Arterial punctures, often performed to collect blood samples or arterial blood gases (ABG), are similarly common in ED, with first-attempt failure rates reported at approximately 10%.

Failed punctures result in deterioration of the patient's vein and arterial capital, as well as causing pain, stress, and delays in medical care. They also create highly demanding situations for nursing professionals and lead to increased use of human and material resources. To mitigate these issues, certain predisposing factors for DIVA patients have been identified, including obesity, oedema, previous cannulations, and hypotension. Additionally, support tools such as the DIVA scale for pediatric patients and the A-DICAVE scale, validated in 2020 by Dr Salleras, have been developed. The latter is specifically designed for adult patients attending ED. However, no validated scales currently exist for identifying patients at risk of difficult ABG sampling.

Once patients with DIVA are identified, or when difficulties in performing ABG are anticipated, healthcare professionals can employ ultrasound-guided techniques to facilitate these procedures. Ultrasound allows for easier identification of vascular access points, as well as real-time confirmation of puncture success and correct SPVC placement.

Although an increasing number of authors advocate for the use of ultrasound in PIVC placement, existing literature primarily focuses on surgical, anesthetic, or pediatric patients. Consequently, ultrasound-guided techniques are not yet widely adopted, and patients continue to experience the consequences of multiple failed attempts. In the context of ED, studies such as those by Dr Salleras and Rodríguez-Herrera highlight the feasibility and benefits of these techniques. Nevertheless, ultrasound-guided vascular access has not yet been systematically implemented through standardized protocols.

This present study aims to provide evidence on the utility of validated scales for identifying DIVA patients, as well as the benefits of ultrasound-guided vascular punctures in ED. It will consider not only procedural success rates but also the satisfaction of healthcare professionals, patients, and their families.