Antegrade Versus Retrograde IV for Blood Draws
Condition: There is no Focus on Any Specific Condition
Study type: Interventional

Summary: 
      The purpose of this study is to compare success rates of antegrade and retrograde intravenous
      (IV) catheters in their ability to aspirate 20 milliliter blood sample within a 2 minute time
      frame, 3 hours after initial insertion. Antegrade IV catheters are placed identically to
      conventional IV catheters, with the end of the catheter pointed toward the direction of blood
      flow to the heart. Retrograde catheters are placed "backwards" with the end of the catheter
      pointed away from the direction of venous blood flow. The hypothesis is that retrograde IVs
      will have a significantly higher success rate of blood draw at the 3 hour time mark without
      use of a proximal tourniquet.
    

Detailed description: 
      1. Patients scheduled for surgery under general anesthesia at the University of Iowa
           Hospitals and Clinics (UIHC) will be recruited pre-operatively in the Day of Surgery
           Admissions (DoSA) rooms before their surgery takes place. Once the subject is recruited
           and has signed a consent form, they will be randomized to either retrograde or antegrade
           IV. Once in the operating room and general anesthesia has been induced, a 20 gauge 30
           millimeter catheter will be placed in a vein of one of the upper extremities by an
           anesthesiologist member of the research team. A drape will obscure viewing of the
           procedure by the clinical anesthesia provider. They will then connect the catheter to an
           IV tubing set and cover the insertion site with a opaque towel, so as to blind the
           anesthesia provider caring for the patient in the OR.

        2. 0.9% normal saline (NS) will be infused at a rate of 20 milliliters (mL) per hour to
           keep it open (TKO) and it will not be used for drug infusion.

        3. Three hours after insertion, the anesthesia provider in the OR will attempt a blood draw
           from a stopcock 33 inches from the catheter. A successful 20 mL blood draw must be
           achieved within 2 minutes after attempt is started or it will be defined as a failed
           attempt. If blood draw fails, an upper arm tourniquet will be placed and the blood draw
           will be reattempted following the same guidelines as the initial attempt. After every
           blood draw, 10 mL of NS will be flushed back through the IV.

        4. At the end of surgery, within 30 minutes of extubation, the anesthesia provider in the
           OR will attempt a blood draw from a stopcock 33 inches from the catheter. A successful
           20 mL blood draw must be achieved within 2 minutes after attempt is started or it will
           be defined as a failed attempt. If blood draw fails, an upper arm tourniquet will be
           placed and the blood draw will be reattempted following the same guidelines as the
           initial attempt. After every successful blood draw 10 mL of NS will be flushed back
           through the IV.

        5. The IV will be saline locked at the end of the case.

        6. The IV will be removed within 15 minutes upon arrival in the Post Anesthesia Care Unit
           (PACU) by the same anesthesiologist member of the research team who placed it and the
           site will be dressed appropriately.

        7. Follow up will happen on post-operative Day 1 (POD1) either in person if the patient is
           admitted to a UIHC inpatient unit or via a phone call if they are discharged before
           POD1. At this POD1 check, the patient will be asked about the prior IV site: level of
           pain, if there is a hematoma, or possible infection. There will be a maximum of 3
           attempts to contact the subject. This data will be gathered by a research coordinator
           member of the research team who is unaware of which study arm the subject was randomized
           to.

        8. A second follow up will happen on 14 days after the surgery/IV placement via a phone
           call. Again, the patient will be asked about the prior IV site: level of pain, if there
           is a hematoma, or possible infection. There will be a maximum of 3 attempts to contact
           the subject. This data will be gathered by a research coordinator member of the research
           team who is unaware of which study arm the subject was randomized to.
    

Intervention name(s): Peripheral intravenous catheter placement; Blood draw; Peripheral intravenous catheter; To keep open (TKO) infusion of 0.9% normal saline
Intervention type(s): Procedure; Other; Device; Drug
Intervention description(s): The region of the upper extremity in which the IV will be placed will be prepped with chlorhexidine and a proximal elastic tourniquet is applied to the upper arm. A 20 gauge 30 millimeter IV catheter is inserted into an upper extremity vein by an anesthesiologist in either an antegrade or retrograde direction depending on which treatment arm the study subject is randomized to.; A 20 milliliter(mL) syringe will be connected to the study IV tubing and used to aspirate 20 mL of blood from the study IV catheter. If 20 mL are unable to be aspirated over a 2 minute time frame, a proximal rubber tourniquet will be applied to the upper arm and the blood draw will be reattempted.This will occur twice throughout the study.; A 20 gauge 30 millimeter long BD Insyte(TM) Autoguard(TM) angiocatheter will be used for peripheral intravenous catheter placement as described above.; After placement of the peripheral intravenous catheter, an infusion of 0.9% normal saline will be connected to the catheter and infused at a rate of 20 milliliters per hour to keep open (TKO) for future use by preventing blood clot development within the catheter.
Allocation: Randomized
Intervention model: Parallel Assignment
Intervention model description: Study participants will be randomized to either antegrade or retrograde IV catheter placement. Although 267 patients were consented/enrolled in the study, only 230 patients were ultimately randomized. 37 patients were withdrawn from the study prior to randomization because they no longer met inclusion/exclusion criteria.
Masking: Triple (Participant, Care Provider, Outcomes Assessor)
Primary purpose: Supportive Care