The efficacy of ultrasound-guided peripheral intravenous cannulation versus the landmark technique in emergency department patients with difficult intravenous access: A systematic review and meta-analysis

Introduction: The aim of this study was to review the evidence comparing the traditional landmark technique with the ultrasound-guided cannulation technique for peripheral intravenous catheter insertion in emergency department patients with difficult intravenous access (DIVA).
Methods: A systematic review and meta-analysis was performed in accordance with PRISMA-guidelines. The protocol was prospectively registered on PROSPERO (CRD42024573146). PubMed, Cochrane, EMBASE, and CINAHL were searched between August 2024 and April 2025. Bias assessment was performed using Revised Cochrane Risk of Bias tool for randomized trials. Randomized controlled trials of emergency department patients with DIVA were eligible
for inclusion. The primary outcome was first-attempt success rate. Secondary outcomes were number of intravenous insertion-attempts and patient satisfaction. A random-effects meta-analysis plot using DerSimonian and Laird method was used to calculate risk ratio (RR) of the primary outcome measure.
Results: Eight randomized controlled trials with a total of 1477 emergency department patients were included in the review and 940 patients in the meta-analysis. The use of ultrasound in the emergency setting was associated with a higher first-attempt success rate (RR, 1.80; 95% CI, 1.18–2.73; p < 0.01). Secondary outcomes; number of attempts and patient satisfaction had heterogenous results. The small number of studies included in the meta-analysis is a limitation.
Discussion: Ultrasound guided cannulation improved the first-attempt success rate compared to the traditional landmark technique in patients with DIVA. Future policy makers should consider the use of ultrasound guidance as the first choice in order to reduce unnecessary insertion attempts in emergency department patients.