Cardiac Anesthesia Subcommittee Minutes

August 22, 2022

1:00pm – 2:00pm EST

Zoom

Asbahi, Moumen (Beaumont Royal Oak)

Kileny, Joel (Trinity- St. Joseph Ann Arbor)

Billings, Josh

Varelmann, Dirk (Brigham & Women’s)

Bailey, Meridith (MPOG)

Malenfant, Tiffany (MPOG)

Buehler, Kate (MPOG)

Mathis, Mike (MPOG)

Burrage, Peter (Dartmouth)

Muehlschlegel, Danny (Brigham and Women’s)

Brown, Morgan (Boston Childrens)

Riggar, Ronnie (MPOG)

Coleman, Rob (MPOG)

Schonberger, Rob (Yale)

Dubovoy, Anna (Michigan Medicine)

Shah, Nirav (MPOG)

Fisher, Clark (Yale)

Wren, Jessica (Henry Ford Health System)

Guruswamy, Jayakar (Jay) (Henry Ford Health System)

Korenke, Mark (Michigan Medicine)

Griffin, Greg (UNC)

Theurer, Patty (MSTCVS)

Janda, Allison (MPOG)

Jelacic, Srdjan (UWashington)

Johnson, Rebecca (Spectrum Health/UM-West)

Bottiger, Brandi (Duke)

Atwood, Tammy (Henry Ford Allegiance)

Kumar, Vikram (Massachusettes General Hospital)

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. Research/Collaboration Opportunity #2

a. Dr. Drake a cardiac surgeon at the Michigan Society of Thoracic and Cardiovascular

Surgeons (MSTCVS) is developing a peri-interventional cardiac imaging quality program

b. 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)

c. 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

3. Sustainability - Cardiac Considerations

a. Current Measures:

i. 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.

ii. 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

iii. 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.

b. Considerations

i. Currently includes cardiac cases and only captures the anesthesia ventilator

fresh gas flow concepts (not from bypass)

ii. Should we exclude cases with inhaled nitric oxide due to mandatory high flows

for all SUS measures (currently only excluded for SUS-01)?

iii. Does not include any of the pump fresh gas flow or sweep concepts on bypass

iv. 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

v. What are your practice patterns for FGF on bypass?

vi. 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

c. Discussion

i. Josh Billings, MD - should still document/include nitric oxide.

ii. Allison Janda, MD - if Nitric oxide was administered it wouldn’t treat the case

any differently regarding changing our FGFs since the higher FGF are required for

nitric oxide. Feedback for these cases may be less helpful for providers since that

high FGF is non-modifiable.

iii. Kate Buehler - Nitric oxide is picked up through variables mapped to the

associated nitric oxide MPOG concept.

iv. Allison Janda, MD - We are excluding cases with Nitric oxide for SUS-01. Should

we exclude the entire case? or should we exclude that time period alone?

v. Mike Mathis, MD - Excluding the time period of nitric oxide only will be difficult

unless it is a minute-by-minute capture.

vi. Allison Janda, MD - We should consistently either include or exclude Nitric oxide

for both SUS-01, SUS-02 and SUS-04. You can’t change or really avoid the high

FGF with Nitric Oxide.

vii. Kate Buehler - Including Nitric Oxide impacts a very small number of non-cardiac

cases which is why we excluded them originally and the change in performance

scores is very small.

viii. Vikram Kumar, MD - I would advocate for excluding cases with Nitric oxide from

SUS-01/02/04. It might be better to focus on flagging cases without Nitric oxide

to improve performance.

ix. Consensus: Exclude Nitric Oxide cases from all Sustainability measures.

4. TEMP-07 (Hyperthermia avoidance):

a. Definition Update: % 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)

b. The Perfusionist Work Group met earlier this year and made some suggestions that have

been incorporated, thank you!

c. 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

d. Recommended discussing with your institutional teams prior to presenting the measure

data

e. Quick poll: What have you done to reach out to your institution’s perfusionist teams

and what has their feedback been?

f. Discussion

i. Josh Billings, MD (via chat) - our usual care is to limit nasal temp to 37 when

rewarming, so this measure is consistent with our institutional protocols..

2. Glucose Management - Cardiac Literature Review

a. 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 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

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. Anna Dubovoy, MD - TAVRs are much shorter and might be difficult to

have meaningful impact.

2. Mike Mathis, MD - I agree with Anna. Glucose management matters for

all cases however if part of our goal is to understand how our glycemic

management changes over time, its a much fairer comparison across

institutions to include all. It might be worth looking at performance

breakdown and counts for these different case cohorts.

3. Josh Billings, MD - Through assessment of the literature we have

determined this is important to measure, but currently we don’t have

plans to look at whether or not implementing these measures/flags

impact patient outcomes. To start we may want to include all to collect

more data and then do a further sub group analysis.

4. Allison Janda, MD - Our current infrastructure doesn’t currently support

‘sub’ quality measures, although that is something we’re working

towards. If we wanted to analyze two separate cohorts we would need

to create two separate measures. By flagging cases within one measure,

they can look more into which cases are flagged and complete the

analysis that way. If all case types are included in a single measure, can

filter by case type to see the change in performance for each cohort.

ii. Any considerations for escalations of insulin treatment?

1. Anna Dubovoy - Hyperglycemia is a focus of ours

2. Allison Janda - This may be a great feature to include in a future glucose

measure.

iii. Any considerations for frequency of checks?

1. Allison Janda - This may be a great feature to include in a future glucose

measure.

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

resulting in a flag?

1. Vikram Kumar, MD - I worry that we may confuse providers if we set a

threshold of 180 for treatment if the actual STS guideline is that there

shouldn’t be any glucose measurements >180.

2. Allison Janda, MD - Previously we had discussed a lower threshold but

there was concern among the subcommittee of hypoglycemia. We had

been leaning towards the threshold of 180 during previous

subcommittee discussions.

3. Josh, Billings, MD - I agree with the STS definition. Unless we feel

strongly that STS has erred in their own guidelines, we should try to

align with them.

4. Allison Janda, MD - Our policy at Michigan is to treat > 150 and since the

glucose tends to increase when we go on bypass, we escalate treatment

quickly but are frequently getting above 180. We are currently working

on this with our endocrinologists.

5. Mike Mathis, MD - When we introduce a measure, there is a certain

amount of QI that happens and as we improve and involve, we dial up

the pressure and build a tighter measure. You want to calibrate the

measure so it is achievable. Another approach then is to build these

measures in stages starting with an ‘easier’ threshold as we learn about

these cases.

6. Kate Buehler - This is an extremely low denominator on a monthly or

quarterly basis so will be able to quickly assess the 5-10 cases that were

flagged. We could start by aligning with STS and assess the same

measure and revisit after it has been implemented.

7. Allison Janda, MD - I agree with simplicity of being as consistent as

possible with the STS guidelines and that we should simplify our

measure to flag any case with glucose >180.

i. Consensus:

i. Restrict GLU-06 to open cardiac cases only and simplify the measure to be

consistent with STS guidelines and flag any case with glucose >180, and develop

a second process measure at our next meeting. Table the escalating glucose

measure for consideration.

4. Next Meeting: November 2022

a. Provide preliminary data for GLU-06 with a flag for ANY intraoperative glucose > 180:

likely an informational measure at this point

b. Provide preliminary data for GLU-07 with threshold of glucose > 180: treated Y/N

c. Provide preliminary data for GLU-07 with threshold of glucose >150: treated Y/N

d. Unblinded Review

i. TEMP-06 and TEMP-07 measure performance data for your hospital will be

included as your hospital is represented on the Cardiac Subcommittee

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

measures with the institution names visible (examples to follow)

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

statement beforehand

iv. 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

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

members of the Cardiac Subcommittee

5. Cardiac Anesthesia Subcommittee Membership

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

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

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

Meeting adjourned at 1404

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