MPOG Cardiac Anesthesia Subcommittee Meeting

August 22, 2022

Agenda

• Welcome & announcements

• Research opportunity discussion: expert-based cardiac anesthesiology

non-technical skills assessments

• Sustainability Measure cardiac considerations

• Hyperthermia avoidance (TEMP-07) collaboration update

• Glucose management measure specification update and discussion

• Discussion of unblinded measure performance review for next meeting

• Next steps

Introductions

• ASPIRE Quality Team

– Allison Janda, MD – MPOG Cardiac Anesthesia Subcommittee Lead

– Michael Mathis, MD – MPOG Director of Research

– Kate Buehler, MS, RN – Clinical Program Manager

• Cardiac Anesthesiology Representatives joining us from around the US!

Research Opportunity

● The VARSITY Surgery group is conducting a study as a part of our

NHLBI-funded R01 titled “Reuse of Operating Room Team View Digital

Recordings of Cardiac Surgery for Evaluating Non-Technical Practices”

that seeks to:

(i) learn more about the relationship between peer based

assessments of intraoperative non-technical practices and

risk-adjusted complication rates after cardiac surgery

(ii) evaluate the feasibility of automating computer-based

analyses of digital recordings to assess intraoperative

non-technical practices

Research Opportunity

● They plan to recruit cardiothoracic surgeon peer assessors, cardiac anesthesiology

peer assessors, and perfusion peer assessors

● The group is inviting attending cardiac anesthesiologists to participate as peer

reviewers

● Time commitment:

- Fill out the Peer Reviewer Informed Consent form (5 mins)

- Complete a demographic survey (5 minutes)

- Complete a ~45-50 minute training on a validated anesthesia non-technical

skills assessment tool (ANTS)

- Sign an attestation form prior to viewing any recordings and attest to

adhering to data privacy

- Review and assess video segments representing cardiac surgery operations

(~10 minutes each)

- There is no pre-specified number of recorded segments you may analyze

Research Opportunity

● Reviewers will receive a $45 Amazon gift card after completing each peer

assessment assignment

● If you or a colleague is willing to participate, please fill out the Peer Reviewer

Informed Consent and email me (ajanda@med.umich.edu) or Korana

Stakich-Alpirez (kstakich@med.umich.edu) and we will request your contact

information to set up a UMich account to view the trainings and video

assessments

Research/Collaboration Opportunity

● Dr. Drake a cardiac surgeon at MSTCVS is developing a peri-interventional

cardiac imaging quality program

● Asking our subcommittee for any interested individuals to have a seat at the

table as this program is being developed (inside and outside the state of

Michigan)

● If you or a colleague is willing to participate, please email me

(ajanda@med.umich.edu) and I will connect you with Dr. Drake with MSTCVS

SUS-01, SUS-02, and SUS-04 Cardiac Considerations

● SUS-01: Percentage of cases with mean fresh gas flow (FGF) equal to, or less

than 3L/min, during administration of halogenated hydrocarbons and/or

nitrous oxide.

● SUS-02: Percentage of cases where carbon dioxide equivalents normalized by

hour for cases receiving halogenated agents and/or nitrous oxide is less than

carbon dioxide equivalents of 2% sevoflurane at 2L FGF = 2.58 kg CO2/hr

during the maintenance period of anesthesia

● SUS-04: Percentage of cases with mean fresh gas flow (FGF) equal to, or less

than 2L/min, during administration of halogenated hydrocarbons and/or

nitrous oxide.

SUS-01, SUS-02, and SUS-04 Cardiac Considerations

● Currently includes cardiac cases

● Only captures the anesthesia ventilator fresh gas flow concepts

● Should we exclude cases with inhaled nitric oxide due to mandatory high

flows?

● Does not include any of the pump fresh gas flow or sweep concepts on

bypass

● While on bypass, we tend to put our FGFs down to 0.2L/min so that is what

would be captured by MPOG and the SUS measures

- What are your practice patterns for FGF on bypass?

● Since we as anesthesiologists do not contribute to the decision as to what

FGF or sweep the perfusionists are running on bypass, limiting those FGFs is

very challenging, and sweep isn’t captured by all institutions in MPOG, we

did not include those sweep concepts if they are contributed

Hyperthermia Avoidance Measure Update

• 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 rise above 37.5 degrees Celsius while on

bypass for over 5 consecutive minutes (inverse measure)

TEMP-07 Perfusionist Input

• The Perfusionist Work Group met earlier this year and made some

suggestions that have been incorporated, thank you!

• We are working with the Michigan Society of Thoracic and Cardiac Surgeons

(MSTCVS) and their network of perfusionists to publicize and gain their input

prior to releasing the measure

– Recommended discussing with your institutional teams prior to

presenting the measure data

– Quick poll: What have you done to reach out to your institution’s

perfusionist teams and what has their feedback been?

Glucose Measure Literature/Guidelines:

• In a study of 510 patients undergoing cardiovascular surgery and found the incidence

of AKI to be higher in patients with high HbA1c levels preoperatively; Every 1%

increase over 6% in HgA1c levels increased the risk of renal complications by 24%

• Glycemic variability, a standard deviation of all POC-BG readings, is associated with

increased postoperative LOS-ICU, rise in creatinine, and AKI

• A study including 761 cardiac surgery patients and found that diabetics were at

increased risk of infection and glucose control (120-160 mg/dL) reduced the risk of

wound infection in diabetics

• In a randomized controlled trial, moderate glucose control defined as 127-179 mg/dl

was found to be preferable to tight control ≤ 126 in patients undergoing CABG

Glucose Measure Literature/Guidelines Continued:

• Incidence of AKI was higher in patients with time-weighted average intraop glucose

of >150mg/dl (8%) as compared to patients with blood glucose 110-150 mg/dl (3%)

• KDIGO - recommends maintaining blood glucose between 110 - 149 mg/dL in

critically ill patients

• Tight glucose control (<150mg/dl) is seen as controversial as risks of hypoglycemia

are significant: NICE-SUGAR meta-analysis

• Society of Thoracic Surgeons (STS) Practice Guidelines recommend maintaining

serum glucose levels ≤ 180 mg/dL for at least 24 hours after cardiac surgery

• Guidelines for Perioperative Care in Cardiac Surgery from the Enhanced Recovery

After Surgery Society recommends treatment of blood glucose >160-180mg/dL

with an insulin infusion

Next Cardiac Measure: Glucose Management

• GLU-06:

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

procedures under general anesthesia of 120 minutes case duration or longer for

whom any blood glucose measure >/=180mg/dL was either treated with insulin or

rechecked and found to be below 180mg/dL within 60 minutes.

• Timing:

– Start: Anesthesia Start

– End: Anesthesia End

Next Cardiac Measure: Glucose Management

• Concepts Queried:

• Attribution:

– The provider signed in at the first glucose recheck or first administration of insulin.

If neither occurred, then the responsible provider is the one signed in 60 minutes

after the high glucose measurement

Insulin MPOG Concept IDs Glucose MPOG Concept IDs

10229 Insulin Aspart 3361 POC- Glucose (Fingerstick)

10230 Insulin Glargine 3362 POC- Glucose (Unspecified Source)

10231 Insulin Novolin 3405 POC- Blood Gas - Glucose

10232 Insulin NPH 5003 Formal Lab-Glucose, Serum/Plasma

10233 Insulin Regular 5036 Formal Lab-Blood Gas, Glucose

10659 Insulin- Unspecified

Next Cardiac Measure: Glucose Management

• Inclusions:

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

procedures (as determined by Procedure Type: Cardiac phenotype) under general

anesthesia of 120 minutes duration or longer.

• 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

– Cases with age <18

Next Cardiac Measure: Glucose Management

• Limitations:

– Any glucose checks not entered into the EHR will not be captured

• Remaining Questions:

– Restrict to “open cardiac” only? Or also “transcatheter/endovascular”?

– Any considerations for escalations of insulin treatment?

– Any considerations for frequency of checks?

– Also develop a measure directly mirroring the STS threshold of any glucose <180

resulting in a flag?

TEMP-06 is Live and TEMP-07 is coming soon!

● TEMP-06 was released in December, 2021

- Check out your personal and site performance on your

dashboards

- If you see any issues, please reach out to: ajanda@umich.edu

● TEMP-07 will be released soon after further collaboration

● Thank you for all of your input!

Unblinded Review at Next Meeting

• TEMP-06 and TEMP-07 measure performance data for your hospital will be included

as your hospital is represented on the Cardiac Subcommittee

• The unblinded data will consist of site comparison graphs of scores for the two

measures with the institution names visible (examples to follow)

• Members will be asked to register for this meeting and attest to a confidentiality

statement beforehand

• If the Cardiac Subcommittee member from your hospital will not be attending the

meeting and you would like your hospital’s data to not be shown, please let us know

so that your data can be removed from the graphs

• We will also email the quality champions at your institution who may not be

members of the Cardiac Subcommittee

TEMP-06 Performance (past 12 months)

TEMP-07 Preliminary Performance (Inverse Measure)

Goals

• Build 1 cardiac-specific measure in 2021 (completed)

– Post-bypass hypothermia avoidance

• Build 1 cardiac-specific measure in early 2022 (nearly completed)

– On-bypass hyperthermia avoidance

• Plan and build next measure in mid-2022 (in progress)

– Glucose management

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

– Fall 2022 Meeting: November 2022

• Thank you for using the forum for discussion between meetings

References

1. Gumus F, Polat A, Sinikoglu SN, Yektas A, Erkalp K, Alagol A: Use of a lower cut-off value for HbA1c to predict

postoperative renal complication risk in patients undergoing coronary artery bypass grafting. J Cardiothorac

Vasc Anesth 2013; 27:1167–73

2. Bansal B, Carvalho P, Mehta Y, Yadav J, Sharma P, Mithal A, Trehan N: Prognostic significance of glycemic

variability after cardiac surgery. J Diabetes Complications 2016; 30:613–7

3. Hruska LA, Smith JM, Hendy MP, Fritz VL, McAdams S. Continuous insulin infusion reduces infectious

complications in diabetics following coronary surgery. Journal of cardiac surgery. 2005;20(5):403-407.

4. Bhamidipati CM, LaPar DJ, Stukenborg GJ, Morrison CC, Kern JA, Kron IL, Ailawadi G: Superiority of moderate

control of hyperglycemia to tight control in patients undergoing coronary artery bypass grafting. J Thorac

Cardiovasc Surg 2011; 141:543–51

5. Song JW, Shim JK, Yoo KJ, Oh SY, Kwak YL: Impact of intraoperative hyperglycaemia on renal dysfunction after

off-pump coronary artery bypass. Interact Cardiovasc Thorac Surg 2013; 17:473–8

References

6. KDIGO. 2012. “KDIGO 2012 Clinical Practice Guideline for the Evaluation and Management of Chronic Kidney

Disease.” https://kdigo.org/wp-content/uploads/2017/02/KDIGO_2012_CKD_GL.pdf.

7. NICE-SUGAR Study Investigators, Finfer S, Chittock DR, Su SY-S, Blair D, Foster D, Dhingra V, Bellomo R, Cook D,

Dodek P, Henderson WR, Hébert PC, Heritier S, Heyland DK, McArthur C, McDonald E, Mitchell I, Myburgh JA,

Norton R, Potter J, Robinson BG, Ronco JJ: Intensive versus conventional glucose control in critically ill patients.

N Engl J Med 2009; 360:1283–97

8. Lazar HL, McDonnell M, Chipkin SR, Furnary AP, Engelman RM, Sadhu AR, Bridges CR, Haan CK, Svedjeholm R,

Taegtmeyer H, Shemin RJ, Society of Thoracic Surgeons Blood Glucose Guideline Task Force: The Society of

Thoracic Surgeons practice guideline series: Blood glucose management during adult cardiac surgery. Ann

Thorac Surg 2009; 87:663–9

9. 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

Thank you!

Allison Janda, MD

MPOG Cardiac Anesthesia QI Subcommittee Lead

ajanda@med.umich.edu