Stick Or Switch: The Diminishing Returns Of Repeated Peripheral Intravenous Access Attempts In Hypotensive Trauma Patients

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BACKGROUND: Peripheral intravenous (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. STUDY DESIGN: We analyzed data from audiovisual recordings of trauma resuscitations from a multicenter prospective study of vascular access in hypotensive (SBP <90mmHg) patients. The primary outcome was 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. RESULTS: 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 OR 1.92, 95% CI 1.22-3.03, p=0.005) and the presence of a measurable initial systolic blood pressure (adjusted OR 1.84, 95% CI 1.06-3.20, 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 prior success dropped from 70% on the first attempt to 54% on the second and 39% on the third. CONCLUSIONS: PIV access in hypotensive trauma patients succeeds approximately two-thirds of the time. The marginal yield of sequential PIV attempts declines substantially after two failed attempts. These findings support a 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.