Written by Megan Hilbert
Regardless of anticipated difficulty of placement of peripheral intravenous catheter (PIVC) in a pediatric patient, ultrasound-guided insertion results in improved success.
An EPIC win for DIVAs
PIVC has a less than 50% initial success rate on first attempt in pediatric patients. This results in increased pain and anxiety. In patients with difficult intravenous access (DIVA), prior studies have shown improved first-pass success with use of ultrasound. This was a randomized clinical trial that looked at first-pass success in all-comer pediatric patients. Patients were first assigned a DIVA risk (low, medium, high)* and randomized to standard technique group (palpation and visualization) or intervention group (ultrasound-guided).
Primary outcome was first-time insertion success. Secondary outcomes were number of insertion attempts, total PIVC insertion failure, dwell time, patient-reported pain on insertion, consumer satisfaction, PIVC post-insertion failure, and healthcare costs.
Ultrasound was more successful on the first attempt compared to standard approach in totality (85.7% vs. 32.5%; RD 53.6%; 95%CI 41.7%-65.4%; P<.001), and across all DIVA categories: low risk 30.8% RD (95%CI 8.1%-53.5%), medium risk 56.2% RD (95%CI 37.1%-75.3%), and high risk 69.6% (95%CI 52.3%-87.0%). Ultrasound also outperformed in secondary outcomes except for dwell time and device removal due to failure (no statistically significant difference noted). Standard approach did, however, have overall lower healthcare costs ($58.20 vs. $67.53; unit price per ultrasound use was the driver of price change).
This was a very well-done study, with a large sample size and generalizable results given all DIVA risk categories were included.
How does this change my practice?
I currently work in a community practice where we see a smaller proportion of pediatric patients. With lower reps comes increased stress. For future kids that come in needing peripheral access, I will recommend that my nursing staff look with ultrasound to improve our initial success regardless of anticipated difficulty level.
*DIVA risk explanation from the paper
- High – urgent insertion, no visible or palpable veins, documented DIVA or severe comorbidities, <18 months, and severe anxiety or needle phobia
- Low – low clinical urgency, multiple visible and palpable veins, previously well, age > 3 years, and minimal anxiety
- Medium – time critical, few visible or palpable veins, multiple attempts in the past, multiple admissions or comorbidities, age ≤ 3 years, and moderate anxiety
Source
First-Attempt Success in Ultrasound-Guided vs Standard Peripheral Intravenous Catheter Insertion: The EPIC Superiority Randomized Clinical Trial. JAMA Pediatr. 2025 Mar 1;179(3):255-263. doi: 10.1001/jamapediatrics.2024.5581. PMID: 39869351
