Cardiac Anesthesia Subcommittee Minutes

December 13, 2022

1:00pm – 2:00pm EST

Zoom

Atwood, Tammy (Henry Ford Allegiance)

Kertai, Miklos (Vanderbilt)

Bailey, Meridith (MPOG)

Kumar, Vikram (Massachusetts General Hospital)

Barrios, Nicole (MPOG)

Low, Ying (Dartmouth)

Bottiger, Brandi (Duke)

Malenfant, Tiffany (MPOG)

Brown, Morgan (Boston Childrens)

Mathis, Mike (MPOG)

Buehler, Kate (MPOG)

Riggar, Ronnie (MPOG)

Clark, Melissa (MSTCVS)

Schwerin, Denise (Bronson)

Fisher, Clark (Yale)

Shook, Doug (Brigham & Women’s)

Heiter, Jerri (Trinity - St. Joseph Ann Arbor)

Theurer, Patty (MSTCVS)

Janda, Allison (MPOG)

Venkataramani, Ranjani (UCSF)

Katta, Guarav (Henry Ford Health System)

Welle, Erin (University of Michigan)

Meeting Summary

1. Research Opportunity

a. 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

b. They plan to recruit cardiothoracic surgeon peer assessors, cardiac anesthesiology peer

assessors, and perfusion peer assessors

c. The group is inviting attending cardiac anesthesiologists to participate as peer

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

assessment assignment

d. Time commitment:

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

ii. Complete a demographic survey (5 minutes)

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

assessment tool (ANTS)

iv. Sign an attestation form prior to viewing any recordings and attest to adhering

to data privacy

v. Review and assess video segments representing cardiac surgery operations (~10

minutes each)

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

e. 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

2. Glucose Management - Cardiac Literature Review

a. MSTCVS (Michigan Cardiac Surgery CQI) has chosen glycemic management as a focus

area for 2023. MPOG is aligning with these efforts with the new glycemic management

measure: GLU-06-CARD

b. Glucose Measure Literature/Guidelines (full literature review document here):

i. 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%

ii. Glycemic variability, a standard deviation of all POC-BG readings, is associated

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

iii. 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

iv. 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

v. 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%)

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

critically ill patients

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

hypoglycemia are significant: NICE-SUGAR meta-analysis

viii. Society of Thoracic Surgeons (STS) Practice Guidelines recommend maintaining

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

ix. 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

3. Next Cardiac Measure: GLU-06

a. Current form from the discussions the last meeting: 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.

b. Measure Period: Anesthesia Start → Anesthesia End

c. MPOG Concepts Considered

d. 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.

e. 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.

f. Exclusions

i. ASA 6

ii. Organ harvest (CPT: 01990)

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

case type phenotype

iv. Within the general cardiac case type phenotype, exclude:

Transcatheter/Endovascular, EP/Cath groups and Other Cardiac

v. Cases with age <18

g. Limitations: Any glucose checks not entered into the EHR will not be captured

h. Remaining Questions:

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

1. After discussion, keep to “open cardiac” for now.

ii. Ok to continue validating and proceed with publishing in early 2023?

1. After discussion, ok to proceed with validating, will bring any additional

questions or changes to the group via Basecamp and aim to publish

before our next meeting.

i. Discussion:

i. Mike Mathis (MPOG Research Director): Should we include other cardiac-like

cases, like transcatheter/endovascular? At face value, seems like we should

include all cardiac case types but the primary measure should focus on open

cardiac so you can compare teh same kind of case across sites and then a

secondary group of cases to track glucose measurement for the other case types

1. Douglas Shook (Brigham and Women’s): I agree. I consider transcatheter

cases as cardiac procedures and the more we include them in our

discussion it sets a standard that we consider those patients to be

included in our domain.

2. Allison Janda (MPOG Cardiac Sub. Chair): I agree. Ideally we would be

able to toggle to open cardiac vs. transcatheter cases only. However,

some of these cases may not be very long whereas we may want to only

focus more granularly at open cardiac as a first step and have the

discussion later on if we want to add them in.

a. Douglas Shook (BWH): Sounds reasonable.

ii. Morgan Brown (Boston Children’s) via chat: Do you think this amount of

variation means that people don’t follow/believe in this metric? We don’t stick

to this at Boston Children’s, but we are a children’s hospital with a young adult

population.

1. Allison Janda (MPOG Cardiac Sub. Chair): This is a very interesting point.

We are on the low end of performance for this measure at U of M and it

isn’t because we don’t believe in it or try to follow it but more so that

the first glucose we take are within normal ranges and then need to

improve on anticipating when the glucose will rise. We definitely believe

glucose management is important in cardiac cases..

2. Mike Mathis (MPOG Research Director): I don’t think any institution

would say they don’t care about taking care of their patients but more

so, we’re busy and have lots going on during these cases. During the

Michigan MSTCVS meeting, the discussion led to more of a

cross-collaboration issue between perfusionists and anesthesiologists in

communicating the results and following up with insulin treatment.

Excited to see what happens when we start working on this measure

and discussing it during this subcommittee.

a. Erin Welle (University of Michigan) via chat - To add on to Mike, I

think it's also a function of how much plegia the surgeon wants

and variation in perfusionist practice during plegia

administration. there's a wide variation at U of M how much

plegia is being given

3. Guarav Katta (Henry Ford Health System): Is this useful information for

me to have as a cardiac anesthesiologist? Yes- it is useful for me to look

at these cases and determine if there was anything different I could have

done differently when reviewing these cases. If we restrict ourselves to

only open cardiac, I think we’ll have more cases excluded over time as

we move away from open cardiac as an approach procedurally. Can

address that longer term.

4. Vikram Kumar (MGH): Considering the utility of this measure - should

we add a limit for time frame to assess how long it was >180mg/dL

before requiring treatment? Also, in support of looking at open cardiac

only at this point.

a. Allison Janda (Cardiac Sub. Chair): Resounding feedback from

the last meeting was we don’t know how long is too long for

exposure to a high glucose to result in a poor outcome. Great

research project but we don’t know what the time duration

would be at this point.

b. Mike Mathis (MPOG Research Director): Agree this is a great

research project and we will do this.

iii. Clark Fisher (Yale) via chat: I apologize, since I wasn’t able to make the last

meeting - do we have a sense of how many of the flagged cases had an out of

range glucose the first time during the case that an anesthesiologist

encountered them?

1. Allison Janda (Cardiac Sub. Chair): This is an interesting point. Should

these patients be included or excluded? Currently we are including

these cases and are looking Anesthesia start to Anesthesia End. The

overall approach I use is to treat the elevated glucose in the holding

room prior to the case starting so that it should be lower (ideally <180)

when we recheck it on our first ABG. Even for patients with an elevated

glucose at baseline, there is utility in flagging the case for review to

reflect on whether we should improve our management just prior to the

OR as well even though this measure captures anesthesia start until

anesthesia end.

2. Clark Fisher (Yale): I would prefer to exclude them but not to the extent

of holding up this measure - especially patients coming from inpatient

who have not been managed well prior and there is limited time to treat

glucose at the beginning of the case with all other anesthesia tasks

a. Allison Janda (MPOG Cardiac Sub. Chair): We still want to know

if we’re managing these patients well or not, so I’m not sure if

we want to exclude them. Definitely a gray zone- we do need a

way to at least flag these patients differently.

iv. Brandi Bottiger (Duke) via chat - Allison, thinking of your idea of a staged

approach. Ultimately, will there be a way to view “all cardiac cases” with metric

performance, and be able to filter to bypass cases or DHCA?

1. Allison Janda (MPOG Cardiac Sub. Chair) - We currently don’t have these

filters. Determining which cases had bypass or not is difficult based on

documentation since it is so variable at different institutions. Even if we

did have the ability to toggle/filter, It would not be 100% accurate -

more like 90% accurate for bypass cases for example.

2. Brandi Bottiger (Duke) - That’s understandable and can understand it

must be a mapping nightmare

3. Allison Janda (MPOG Cardiac Sub. Chair) - We are getting a little better

at catching some of these mismappings during the onboarding process

for new sites. I think that this is a potential filter for the future.

4. Kate Buehler (MPOG Clinical Program Manager)- Hopefully in 2023

those filters for some case types that Dr. Bottinger mentioned will be

available!

v. Tammy Atwood (Henry Ford Allegiance) via chat - Completely agree with

Michael's comments. We used to use a dextrose base cardioplegia and it

required a lot of communication and timing on insulin dosing, cardioplegia

dosing and drawing of blood glucoses to measure.

1. Allison Janda (MPOG Cardiac Sub. Chair) - It would be hard to have

cardioplegia type as a covariate because this is not routinely

documented in MPOG, however we are doing adjusted AKI and

mortality measures which are on the horizon.

vi. Guarav Katta (Henry Ford Health System): Would it be possible to find out at the

granular level what type of cardioplegia was used with the cases that are

hypoglycemic.

1. Mike Mathis (MPOG Research Director) - Yes, however only with STS

integrated data with MPOG. With MPOG alone its challenging to do but

we are continuing to develop phenotypes in this area.

2. Allison Janda (MPOG Cardiac Sub. Chair) - STS data only applies to 8 to 9

institutions that are currently merging their STS data with MPOG.

3. Tammy Atwood (Henry Ford Allegiance) via chat - I wonder if this has

been reviewed with PERForm data specifically (cardioplegia and glucose

levels) or is this part of the STS data you review. I realize that doesn't

include all of MPOG participants.

vii. Consensus: Restrict to open cardiac only. Continue validating and proceed with

publishing this measure next year.

4. Unblinded Data Review (all site-specific comments redacted and all institution names, if

mentioned redacted)

a. All sites that perform >75 open cardiac procedures annually are presented on the slides

to follow

b. This is a closed meeting: registration required to receive the Zoom link.

c. Only those sites who have a participant on the cardiac subcommittee are unblinded

d. Cardiac Anesthesia Champions were notified that unblinded data would be shared and

were given the opportunity to opt out

e. No sites emailed us to express a desire to be excluded from this review

f. TEMP 06 and TEMP 07 unblinded data presented & discussed during the meeting:

unblinded data removed from slide deck before posting to the website. Please contact

the Coordinating Center if interested in unblinded data review at a future meeting!

5. Discussion (TEMP-06):

a. Douglas Shook (BWH) - We will definitely have patients who will fail this. We go upstairs

at 34.5 for specific cases intentionally. My only concern about the 120 minute definition

is that it is possible that some of our take-backs/bleeds that have open cardiac are in this

measure? Those can be more difficult than the ones that are planned scheduled

procedures. good information to know to address those issues.

i. Allison Janda (Cardiac Sub. Chair) - This includes both bypass and non-bypass

cases, but yes, this would include any bring-back that is at least 120 minutes.

b. Erin Welle (University of Michigan) via chat- Is this only looking at the last temperature

before leaving the room? Or are able to look at the temp coming off bypass vs leaving

the room?

i. Allison Janda (MPOG Cardiac Sub. Chair)-This is only looking at the last

non-artifact temperature (and if not available, looks at the first recorded

temperature in the ICU)

c. Guarav Katta (Henry Ford Health System) - If there is no temp within 30 mins of

anesthesia end (pre or post anesthesia end), the flowchart says flag as no available

temperature. Does that count as failure for the unblinded bar graph you posted just now

Allison? Or is that just simply excluded outright?

i. Allison Janda (MPOG Cardiac Sub. Chair) - Yes we still include that case but we

decided to flag cases that didn’t have a temperature within 30 minutes before or

after anesthesia end since there should be continual monitoring and a

temperature taken upon arrival to the ICU.

d. Mike Mathis (MPOG Research Director)- I think the next step is to breakdown the

reasons as to why cases are flagging for this measure and if it’s a data issue or a practice

issue.

i. Allison Janda (MPOG Cardiac Sub. Chair)- If you are reviewing cases and notice a

trend please reach out to the coordinating center. We appreciate any feedback

or mapping improvement suggestions you may have for your institution.

e. Discussion (TEMP-07):

i. Clark Fisher (Yale): Would be valuable to break out the hypothermic arrest

patients- sometimes the speed at which we come off bypass and exit the room

may be a factor. Looks like we may need to convince providers to slow down and

take time to warm the patient before leaving the room

1. Allison Janda (MPOG Cardiac Sub. Chair)- We can’t break out the HCA

patients at this point, but we tend to have a longer post-bypass time at

our institution and continue to warm the patient so I think that could be

contributing to the ability to warm patients post bypass.

ii. Brandi Bottiger (Duke): I could think of 10 questions I could ask just looking at

this graph- thanks for doing this to start the conversation around practice.

iii. Douglas Shook (BWH): This data really makes me think- would be nice to see the

sites

iv. Erin Welle (U.Michigan) - I'd be curious to see what other institutions' protocols

are for warming, because that definitely is driving our numbers here

v. Ying Low (Dartmouth) - This has been an ongoing discussion with our surgeons.

We do mostly CABG/Valve procedures who could be warmer after surgery.

Would be interested in looking at transfusion data compared to hypothermia

rates to foster communication with the surgeons.

1. Allison Janda (MPOG Cardiac Sub. Chair) - agree there are variation in

concerns across institutions as well as case type.

2. Brandi Bottiger (Duke) - Would be interesting to overlap bleeding

metrics with hypothermia. Jinx

vi. Clark Fisher (Yale) via chat - Speaking to the cultural basis of practices,

fascinating to see how much colder the Northeast is

vii. Mike Mathis (MPOG Research Director) - If others have stories like Ying, in which

MPOG could help provide data to make compelling case to change practice

patterns, let us know.

viii. Guarav Katta (Henry Ford): Of the top 5 institutions that are doing well on both

measures AND have a lot of cases, looks like [redacted] is the only one. I’d be

interested if they at some point could share their thoughts. They appear to be

the institution with large numbers of cases and doing well on both

6. Cardiac Anesthesia Subcommittee Membership

a. Next meetings:

i. April 2023

ii. August 2023

iii. Nov/Dec 2023

b. Open to all anesthesiologists or those interested in improving cardiothoracic measures

i. Do not have to practice at an active MPOG institution to participate

c. Thank you for continued use of the Basecamp forum for discussion between meetings!

Meeting adjourned at 1407

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