Cardiac Subcommittee Slides 12.22.21

MPOG Cardiac Anesthesia Subcommittee Meeting

December 22, 2021

Agenda

• Welcome & quick summary of progress

• Cardiac procedure type phenotype update

• Hypothermia avoidance (TEMP-06) update and

review of validation

• Hyperthermia avoidance measures specification discussion

• Future measure discussion of preliminary data

• Next steps

Introductions

• ASPIRE Quality Team

– Allison Janda, MD – MPOG Cardiac Anesthesia Subcommittee Lead

– Michael Mathis, MD – MPOG Director of Research

– Kate Buehler, MSN – Clinical Program Manager

• Cardiac Anesthesiology Representatives joining us from around the US!

General QI Committee Cardiac Considerations

TRAN-01: Percentage of cases with a blood transfusion that have a

hemoglobin or hematocrit value documented prior to transfusion

• Exclude peds < 18y

• Exclude cardiac cases

• Exclude transfusion cases with profound/prolonged hypotension

requiring vasopressor

• Massive Transfusion Exclusion: Update default PRBC unit definition

change from 350 300mL

TRAN-02: Percentage of cases with a post transfusion hemoglobin or

hematocrit value greater than or equal to 10 g/dL or 30%

• Exclude Patients < 18yo (per pediatric subcommittee)

• Exclude cardiac cases

General QI Committee Cardiac Considerations

NMB-01: Percentage of cases with a documented Train of Four (TOF) after

last dose of non-depolarizing neuromuscular blocker

• Remove cardiac exclusion

NMB-02: Administration of Neostigmine, Sugammadex, and/or

Edrophonium before extubation for cases with non-depolarizing

neuromuscular blockade

• Remove cardiac exclusion

Cardiac Procedure Type Phenotype

• Schema:

– Sequentially bins cases based on utilized fields if present

• Current Status:

– Public, continuing to test internally

Post-bypass Hypothermia Avoidance

• Current TEMP-03 Measure:

– % of patients, with procedures >60 minutes under

GA/neuraxial, with at least one body temperature ≥ 36

– Excludes cardiac surgeries

• New TEMP-06 Measure:

– % of patients, ≥ 18 years age, who undergo open cardiac

surgical procedures under general anesthesia of >120

minutes for whom last non-artifact body temperature

prior to anesthesia end was ≥ 35.5

TEMP-06 Measure Details

• Including open cardiac cases

• Last non-artifact temperature documented, if more than one,

preferentially use core temperature

– Use core temperature measure if present in the anesthesia record

within 15 minutes of the last documented non-artifact body temperature

– If no temp. documented or temp below 35.5C pre-anesthesia end, will

accept temps up to 30 mins post-anesthesia end to account for

identification and correction of hypothermia by the anesthesia team

TEMP-06 Measure Temperature Flow Chart

TEMP-06 Preliminary Performance (past 12 months)

*plan to report “N/A” on dashboard for institutions with <100 cases/year meeting inclusion criteria

TEMP-06 – Next Steps

• Currently in PROD (as of today)

• Refining the measure will continue after we launch, please

let us know if you see inappropriately flagged or passed

cases on your dashboards

Hyperthermia Avoidance – Literature Review

• 2020 Updates from the Adult Cardiac Anesthesiology Section of STS

– Avoidance of temp >37 while on bypass

• Guidelines for perioperative care in cardiac surgery: enhanced recovery

after surgery recommendations

– Avoid >37C for arterial outlet blood temperature while on bypass

• STS Practice Guidelines for temperature management while on bypass

– Avoid >37C for arterial outlet blood temperature while on bypass

1. Del Rio JM, Abernathy JJ 3rd, Taylor MA, Habib RH, Fernandez FG, Bollen BA, Lauer RE, Nussmeier NA, Glance LG, Petty JV 3rd, Mackensen GB, Vener DF, Kertai

MD: The Adult Cardiac Anesthesiology Section of STS Adult Cardiac Surgery Database: 2020 Update on Quality and Outcomes. Anesth Analg 2020

doi:10.1213/ANE.0000000000005093

2. Engelman DT, Ben Ali W, Williams JB, Perrault LP, Reddy VS, Arora RC, Roselli EE, Khoynezhad A, Gerdisch M, Levy JH, Lobdell K, Fletcher N, Kirsch M, Nelson G,

Engelman RM, Gregory AJ, Boyle EM: Guidelines for Perioperative Care in Cardiac Surgery: Enhanced Recovery After Surgery Society Recommendations. JAMA Surg

2019 doi:10.1001/jamasurg.2019.1153

3. Engelman R, Baker RA, Likosky DS, Grigore A, Dickinson TA, Shore-Lesserson L, Hammon JW: The Society of Thoracic Surgeons, The Society of Cardiovascular

Anesthesiologists, and The American Society of ExtraCorporeal Technology: Clinical Practice Guidelines for Cardiopulmonary Bypass--Temperature Management During

Cardiopulmonary Bypass. J Cardiothorac Vasc Anesth 2015; 29:1104–13

Hyperthermia Avoidance – Literature Review

• ERAS cardiac recommendations

– Avoid >37.9C while on bypass

• Current cardiac hyperthermia avoidance Anesthesia Quality

Institute measure

– AQI65, for cerebral hyperthermia avoidance defines

hyperthermia as ≥37C while on bypass

• On-bypass Hyperthermia Avoidance AmSECT Guidelines

– Limit arterial outlet blood temperature to <37C to avoid

cerebral hyperthermia. (Class I, Level C)

4. Gregory AJ, Grant MC, Manning MW, Cheung AT, Ender J, Sander M, Zarbock A, Stoppe C, Meineri M, Grocott HP, Ghadimi K, Gutsche JT, Patel PA, Denault A, Shaw A, Fletcher N, Levy JH: Enhanced

Recovery After Cardiac Surgery (ERAS Cardiac) Recommendations: An Important First Step-But There Is Much Work to Be Done. J Cardiothorac Vasc Anesth 2020; 34:39–47

5. https://www.aqihq.org/files/MIPS/2020/2020%20QCDR%20Measure%20Book.pdf

6. Engelman R, Baker RA, Likosky DS, Grigore A, Dickinson TA, Shore-Lesserson L, Hammon JW: The Society of Thoracic Surgeons, The Society of Cardiovascular Anesthesiologists, and The American

Society of ExtraCorporeal Technology: Clinical Practice Guidelines for Cardiopulmonary Bypass--Temperature Management During Cardiopulmonary Bypass.

J Cardiothorac Vasc Anesth 2015; 29:1104–13

Prelim MPOG data: Hyperthermia avoidance >38

Hyperthermia Avoidance Measure Details

• TEMP-07:

– % of patients, ≥ 18 years age, who undergo open cardiac

surgical procedures using cardiopulmonary bypass under

general anesthesia of >120 minutes for whom the

temperature did not rise above 37.5 degrees Celsius while on

bypass for over 10 consecutive minutes

• Timing:

– Cardiopulmonary Bypass Start until Cardiopulmonary Bypass

End (phenotypes exist but need improvement)

Hyperthermia Avoidance Measure Details

• Artifact algorithm:

– Less than 32.0°C (89.6F)

– Greater than 40.0°C (104.0F)

– Any minute-to-minute jumps >0.5°C equivalent

– Example: 0.125°C /15s, 0.25°C / 30s, 1°C / 2mins

• Attribution:

– Any provider signed in for ≥40 minutes from bypass start until

bypass end (or the provider signed in for the greatest number of

minutes during this period, if this period is <40 minutes) per staff

role

Hyperthermia Avoidance Measure Details

• Inclusions:

– All patients, 18 years of age or older, who undergo open cardiac

surgical procedures using cardiopulmonary bypass (as

determined by Procedure Type: Cardiac Open phenotype and

Cardiopulmonary Bypass phenotype) under GA of ≥120 minutes

• Exclusions:

– ASA 6

– Organ harvest (CPT: 01990)

– Non-cardiac cases as defined as those cases not meeting criteria for the

cardiac case type phenotype

– Within the general cardiac case type phenotype, exclude:

Transcatheter/Endovascular, EP/Cath groups and Other Cardiac

– Non-CPB cases

– Cases with age <18

TEMP-07 Perfusionist Input

• TEMP-07:

– % of patients, ≥ 18 years age, who undergo open cardiac

surgical procedures using cardiopulmonary bypass under

general anesthesia of >120 minutes for whom the

temperature did not rise above 37.5 degrees Celsius while on

bypass for over 5 consecutive minutes

• Exclusions/Limitations:

– If starting temp on initiation of bypass is >37.5, consider

excluding that case, or excluding potentially the first 30

minutes of the bypass period

TEMP-07 Perfusionist Input

• Call for additional perfusionist input:

– Please email me (ajanda@med.umich.edu) with the contact

information of any potentially interested perfusionists

• Next perfusionist workgroup meeting:

– End of January/early February

– Will be invited to our next subcommittee meeting

Future Measure Planning

• Top ranked topics:

– AKI avoidance

– 75% ranked in top 3

– AKI-01 version with just cardiac open cases?

– Sharing data in next slide

– Postop. pulmonary complication avoidance

– 67% ranked in top 3

– PUL-02 version with just open cardiac cases?

– Extubation data in import manager would require a deep dig

– Deeper dig: data is poor

– Glucose management and hypotension avoidance

– Both with 42% ranked in top 3

– High variation with glucose performance

– May be challenging to establish thresholds and exclusion periods for

hypotension measures

Cardiac AKI Variation Data

• Adapted AKI-01: Percentage of cases that did not have AKI (the baseline creatinine increased

more than 1.5 times within 7 postoperative days or the baseline creatinine level increased by =

0.3 mg/dL within 48 hours postoperatively) for open cardiac cases

Example of Glucose Variation Data

• Adapted GLU-01 Measure:

– % of cases with perioperative glucose > 200 mg/dL with administration of insulin

or glucose recheck within 60 minutes of original glucose measurement

– Mean: 85% SD: 11%

Example of Glucose Variation Data

• Adapted GLU-01 Measure:

– % of cases with perioperative glucose > 180 mg/dL with administration of insulin

or glucose recheck within 60 minutes of original glucose measurement

– Mean: 79% SD: 14%

Example of Glucose Variation Data

• Adapted GLU-01 Measure:

– % of cases with perioperative glucose > 150 mg/dL with administration of insulin

or glucose recheck within 60 minutes of original glucose measurement

– Mean: 64% SD: 18%

Goals

• Build 1 cardiac-specific measure in 2021

– Post-bypass hypothermia avoidance

• Build 1 cardiac-specific measure in early 2022

– On-bypass hyperthermia avoidance

• Plan and build next measure in mid-2022

– AKI avoidance?

– Glucose management?

– Other?

Cardiac Anesthesia Subcommittee Membership

• Open to all anesthesiologists or those interested in improving cardiothoracic

measures

– Do not have to practice at an active MPOG institution

• Proposed 2022 Meeting Schedule

– Winter 2022 Meeting: February/Early March 2022

– Summer 2022 Meeting: June 2022

– Fall 2022 Meeting: November 2022

• Thank you for using the forum for discussion between meetings