Difficult venous access in some patients such as those with obesity, IV drug use, chronic illness, or vascular pathology often causes increased discomfort and delayed patient care due to multiple attempts to gain venous access. If access is achieved at all, it usually results in a much smaller catheter than needed to provide optimal care for the patient. Ultrasound-guided placement of a peripheral IV in the internal jugular vein is common in the investigators' emergency department and is gaining popularity across the US. This study investigates the utility and safety of placing an ultrasound-guided peripheral IV catheter in the internal jugular vein.

Intravenous access in the emergency department (ED) patient is essential for medication delivery, IV fluid resuscitation, rapid serum laboratory diagnostics, and administration of IV contrast for CT scans. Some patients, such as those with obesity, IV drug abuse, chronic illnesses, or vascular pathology may have difficult IV access. These patients are problematic for the busy ED nurse and physician as this can lead to a time consuming process, which slows efficiency and patient care.

Previously, patients with difficult IV access often required central venous catheterization, a procedure that can result in a number of serious complications (1). More recently, ultrasound guidance has been touted as an effective means to achieve peripheral IV access on these patients (2). In one study (2), there was a 73% first attempt cannulation rate, which seems respectable, but not excellent. Additionally, 8% of the successful IVs failed within one hour (2). Another study compared ultrasonographically guided peripheral IVs to non-ultrasonographically guided IVs, and it found that using ultrasound did not decrease the amount of time or the number of attempts it took to successfully place a peripheral IV (3). Although ultrasound-guided peripheral IV's have a role, there remains room for improvement in being able to achieve rapid IV access in those patients who need IV access on an urgent basis.

It seems that we still have room to improve our ability to obtain difficult IV access, and a relatively new technique may be the answer. Ultrasound guided IVs are typically attempted in the upper extremities, targeting the brachial or basilic veins, but a recently described technique --- the "peripheral IJ" --- involves placement of a peripheral IV catheter in the internal jugular vein (4,5).

The peripheral IJ is gaining popularity in the investigators' ED as a solution to the difficult vascular access patient. In the investigators' clinical experience, it is a quick and easy procedure that is also safe, tolerated well by patients, and requires few resources. Several small studies have concluded that this is a fast and safe procedure and a feasible alternative to central access in the difficult vascular access patient (4-7). These studies mention the theoretical risks as being similar to central venous access such as carotid artery puncture, hematoma, pneumothorax, and line infection, however none of these have actually been reported (4-7). Therefore, we seek primarily to determine the average number of attempts to cannulation for ultrasound-guided peripheral IJ placement. Secondarily, we wish to determine: 1) the prevalence of potential complications related to this procedure 2) the average time it takes the emergency physician to complete the procedure 3) the patient's satisfaction with the procedure. We will compare the data from this study to the published data for other types of ultrasound-guided peripheral IVs.

Inclusion Criteria:

• At least 2 unsuccessful attempts at peripheral IV access by ED nursing
• Age 18 or older

Exclusion Criteria:

• Critically ill patients with clinical indications for emergent central venous access.
• Overlying skin infection
• External jugular vein easily visible for cannulation
• Patient in law enforcement custody
• Patient who is known to be pregnant or self identifies as pregnant
• Patient lacking decision making capacity

We monitored for adverse events throughout the patient's hospitalization, the length of which ranged from a few hours to a maximum of 2 weeks.

The adverse events that we tracked included local hematoma, pneumothorax, arterial puncture, bacteremia/line infection, and line thrombus. Trained research assistants watched line placement to assess for these complications. They also rechecked the line 1 hour after placement, and then once every 24 hours until the line was removed. They also checked the results of CXRs to look for pneumothoraces, and they checked blood cultures results.