MPOG Cardiac Anesthesia Subcommittee Meeting
December 13, 2022
Agenda
• Welcome & announcements
• Research opportunity discussion: expert-based cardiac anesthesiology
non-technical skills assessments
• Glucose management measure (GLU-06)
– Preliminary data
– Specification review & discussion
• Unblinded measure performance review: TEMP-06 & TEMP-07
• Summary and 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
GLU-06 Discussion and Preliminary Data
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%
1
• Glycemic variability, a standard deviation of all POC-BG readings, is associated with
increased postoperative LOS-ICU, rise in creatinine, and AKI
2
• 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
3
• 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
4
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%)
5
• KDIGO - recommends maintaining blood glucose between 110 - 149 mg/dL in
critically ill patients
6
• Tight glucose control (<150mg/dl) is seen as controversial as risks of hypoglycemia
are significant: NICE-SUGAR meta-analysis
7
• Society of Thoracic Surgeons (STS) Practice Guidelines recommend maintaining
serum glucose levels ≤ 180 mg/dL for at least 24 hours after cardiac surgery
8
• 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
9
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 did not exceed 180 mg/dL (and not rechecked
within 30-minutes and found to be </=180 mg/dL) was documented.
• Timing:
– Start: Anesthesia Start
– End: Anesthesia End
Next Cardiac Measure: Glucose Management
• Concepts Queried:
• Attribution:
– The provider signed in at the first blood glucose of >180mg/dL.
– In the event that two or more providers in the same role are signed in, both will
receive the feedback.
Glucose MPOG Concept IDs
3361 POC- Glucose (Fingerstick)
3362 POC- Glucose (Unspecified Source)
3405 POC- Blood Gas - Glucose
5003 Formal Lab-Glucose, Serum/Plasma
5036 Formal Lab-Blood Gas, Glucose
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
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”?
– Ok to continue validating and proceed with publishing in early 2023?
Unblinded Data Review (actual data removed)
Reminders:
Per the terms and conditions outlined during the registration process:
– A culture of openness and trust are critical to the development of such a collaborative effort to improve
quality; and a commitment for confidentiality is required to further the goals of ASPIRE.
– The following examples are to be considered privileged and confidential information and should be
discussed only within the confines of the Cardiac Subcommittee Meeting.
– Any and all patient information.
– Any and all patient identifiers/information which are considered privileged and protected health
information as defined by current HIPAA laws.
– Any specific MPOG QI registry case information.
– Any information discussed regarding a specific site outcome.
– Any reference to a specific MPOG site result or analysis.
– All anesthesiology data presented including but not limited to outcome reports.
– Taking screenshots, pictures or videos of data slides is prohibited.
Site Participation
• All sites that perform >75 open cardiac procedures annually are presented on the
slides to follow
• This is a closed meeting: registration required to receive the Zoom link.
• Only those sites who have a participant on the cardiac subcommittee are unblinded
• Cardiac Anesthesia Champions were notified that unblinded data would be shared and
were given the opportunity to opt out
• No sites emailed us to express a desire to be excluded from this review
TEMP-06
Success:
Percentage of patients, ≥18 years age, who undergo an open cardiac surgical
procedure under general anesthesia of 120 minutes duration or longer for whom the
last non-artifact body temperature measure at the end of the case was greater than or
equal to 35.5 degrees Celsius (or 95.9 degrees Fahrenheit).
Reported as an inverse measure (lower = better)
TEMP-07
Success:
Percentage of patients, ≥ 18 years age, who undergo an open cardiac surgical
procedures using cardiopulmonary bypass under general anesthesia of >120
minutes for whom the temperature was > 37.5 degrees Celsius while on bypass for
over 5 consecutive minutes
Reported as an inverse measure (lower = better)
Goals
• Build 1 cardiac-specific measure in 2021 (completed, published 12/2021)
– Post-bypass hypothermia avoidance
• Build 1 cardiac-specific measure in early 2022 (completed, published 11/2022)
– On-bypass hyperthermia avoidance
• Plan and build next measure in mid-2022 and publish in early 2023 (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 2023 Meeting Schedule
– April 2023
– August 2023
– November or December 2023
• 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
