The primary objective is to determine whether the use of ultrasound guidance compared to standard IV access improves the proportion of successful IV placement on a first attempt for children in a pediatric emergency department who have predicted difficult access by a validated score. Secondary objectives include determining whether ultrasound-guided IV access lowers the overall number of IV attempts and/or reduces time to IV access. The investigators will also examine the duration of IV access and any complications related to IV access in both the traditional and ultrasound guided IV access group.

The proposed study is a randomized trial of ultrasound guided IV access compared to traditional IV access in patients determined to have difficult IV access based on the Difficult Intravenous Access (DIVA) scale. Patients enrolled in the study will be randomized to traditional IV access or ultrasound guided IV access. If randomized to ultrasound guided IV access, the IV will be placed under direct visualization. Following IV placement or when attempts at IV access have ceased, the patient and family will be asked to complete a series of questions related to their satisfaction regarding IV placement. The follow-up phase examining duration of the IV and any related complications will continue until the IV placed as part of the study has been removed.

Inclusion Criteria:

• Emergency department patients ages 0-18 years
• Requiring IV access as determined by emergency department attending physician
• Predicted difficult IV access as defined by a revised DIVA score >3

Exclusion Criteria:

• Unstable patients triaged as a Level 1 triage acuity
• Patients who refuse IV access
• Non-English speaking parent/guardian
• No study team member available to enroll patient
• Parent/guardian does not consent
• Allergy to ultrasound gel