Peripheral intravenous catheter (PIVC) postinsertion failure rates are unacceptable. Ultrasonography is an adjunctive tool that may improve PIVC utilization success.

Determine if ultrasonographically guided (USG) PIVCs placed in the emergency department (ED) significantly decreases postinsertion failure rate, increases utility time, and decreases postremoval complication rate. Determine if catheter-to-vein ratio (CVR) predicts postinsertion failure.

Participants were randomized to either standard or USG cohort. Data collection included participant and PIVC characteristics, vein measurements, postinsertion failure, and postremoval complication. Chi-square analysis compared postinsertion failure rates. Group t-test compared utility times. Postremoval complication rates were compared with standard rate analysis by Fleiss. The receiver operating characteristic curve was calculated to determine if CVR could predict postinsertion failure. An enrollment of 582 was estimated.

A total of 223 patients were enrolled, with 222 PIVCs investigated. Standard cohort included 116 PIVCs and USG cohort included 106 PIVCs. A total of 212 vein diameters were analyzed. USG PIVC insertion did not result in fewer postinsertion failures (p = 0.654) or longer utility time (p = 0.808). Postremoval complications were not significantly lower (p = 0.414). Receiver operating characteristic curve showed a cut-off CVR of ∼ 0.21. Area under the curve was 0.621 (p = 0.063, 95% confidence interval 0.508–0.734).

The USG technique did not decrease postinsertion failure rate, increase utility time, or significantly decrease postremoval complication rate. A CVR predictive of postinsertion failure could not be determined.