Repeated Peripheral Intravenous Access Attempts in Hypotensive Trauma Patients Show Diminishing Returns

Dumas RP, Succar B, Vella MA, Maiga MD, et al. Stick Or Switch: The Diminishing Returns of Repeated Peripheral Intravenous Access Attempts in Hypotensive Trauma Patients. J Am Coll Surg. May 2026.

Peripheral intravenous (PIV) access remains the default first step for vascular access in trauma resuscitation, but in hypotensive patients, repeated failed attempts can cost valuable time. In this multicenter prospective study, Dumas and colleagues used audiovisual review of trauma resuscitations across 18 centers to evaluate 886 PIV attempts in 471 patients with systolic blood pressure <90 mmHg. Overall, PIV placement was successful in 67.1% of attempts. Male sex and the presence of a measurable initial systolic blood pressure were independently associated with successful access, suggesting that success is influenced not only by operator skill, but also by patient physiology.

The most clinically useful finding is the diminishing return of repeated attempts. The first PIV attempt succeeded in 70% of patients, and cumulative success increased to 83% by the second attempt. However, among patients without prior successful access, the marginal success rate fell from 70% on the first attempt to 54% on the second and 39% on the third. 

For surgeons and trauma teams, this supports a more deliberate vascular access strategy: one attempt is reasonable, and a second may be justified, but persistent PIV attempts in a profoundly hypotensive patient may delay resuscitation. In patients without measurable blood pressure, early transition to intraosseous or other alternative access should be viewed not as a failure of PIV placement, but as timely source control for vascular access.