Stick or Switch: Diminishing Returns of Repeated Peripheral IV Access Attempts in Hypotensive Trauma Patients

Peripheral IV (PIV) access is the first-line approach to vascular access in trauma patients. There is no evidence to guide clinicians on when to abandon PIV attempts in favor of alternative access. We sought to characterize PIV success rates, identify factors associated with success, and determine the marginal yield of sequential PIV attempts in hypotensive trauma patients.

We analyzed data from audiovisual recordings of trauma resuscitations from a multicenter, prospective study of vascular access in hypotensive (SBP <90 mmHg) patients. The primary outcome was the PIV attempt success rate. Secondary outcomes included attempt duration and cumulative patient-level success across sequential attempts. Generalized estimating equations with exchangeable correlation structure were used to account for clustering of attempts within patients.

A total of 886 PIV attempts occurred in 471 patients across 18 centers. The overall PIV success rate was 67.1%. Male patient sex (adjusted odds ratio 1.92, 95% CI 1.22 to 3.03, p = 0.005) and the presence of a measurable initial systolic blood pressure (adjusted odds ratio 1.84, 95% CI 1.06 to 3.20, p = 0.03) were independently associated with PIV success. The first PIV attempt was successful in 70% of patients, and cumulative success reached 83% by the second attempt. The marginal success rate among patients without earlier success dropped from 70% on the first attempt to 54% on the second and 39% on the third attempt.

PIV access in hypotensive trauma patients succeeds approximately two-thirds of the time. The marginal yield of sequential PIV attempts declines substantially after 2 failed attempts. These findings support the practice in which alternate vascular access, such as intraosseous access, is actively considered after a single failed PIV attempt in patients without a measurable blood pressure.