Peripheral intravenous access is one of the most common procedures in modern care, yet first-pass success is far from guaranteed. Failed attempts cause pain, delay treatment, consume staff time, and can escalate to more invasive access.
The clearest evidence for ultrasound-guided peripheral access is in patients with difficult intravenous access. A 2025 systematic review found that ultrasound guidance improved first-attempt success compared with the landmark technique. In practical terms, ultrasound is most valuable when veins are deep, poorly palpable, poorly visible, or repeatedly missed.
Better first-pass performance can reduce repeated needle trauma, improve patient experience, and shorten delays to analgesia, fluids, medication, and escalation of care. This is especially relevant in patients with obesity, oedema, chronic illness, previous chemotherapy, or a history of difficult access.
It is important to distinguish ultrasound guidance from near-infrared vein-visualisation technologies. Vein-visualisation tools may be helpful adjuncts, whereas ultrasound guidance has the stronger evidence base for DIVA pathways.
If a service wants the most defensible clinical position, it should emphasize ultrasound-guided access for difficult cases, supported by training, patient selection, and procedural discipline. Adjunctive vein-viewing tools can be presented as potential workflow aids rather than universal solutions.
Dr Yahya Docrat is an anaesthetist based in Johannesburg, South Africa, with clinical experience in perioperative medicine and point-of-care ultrasound applications in anaesthesia, emergency medicine and critical care.