MPOG Cardiac Anesthesia Subcommittee Meeting
March 14th, 2025
Agenda
• Introduction & announcements
• Measure Reviews:
– TEMP-06-C: Hypothermia Avoidance, Cardiac
– TEMP-07-C: Hyperthermia Avoidance, Cardiac
• Measure Update:
– AKI-02-C: Acute Kidney Injury, Cardiac
– ABX-03-C: Antibiotic Re-dosing, Open Cardiac
– ABX-04-C: Antibiotic Selection, Open Cardiac
• Preliminary Data for New Measure
– BP-07-C: Hypothermia Avoidance (MAP < 55 mmHg), Induction, Open Cardiac
– TRAN-05-C: Coagulation Monitoring
• Summary and next steps
Introductions
• ASPIRE Quality Team
– Allison Janda, MD – MPOG Cardiac Anesthesia Subcommittee Chair
– Michael Mathis, MD – MPOG Director of Research
– Henrietta Addo, MSN, RN – MPOG Cardiac Subcommittee Facilitator
• Cardiac Anesthesiology Representatives joining us from around the US!
Seeking Cardiac Subcommittee Vice-Chair
• 2-year term
• Help shape direction of Cardiac Subcommittee
• Measure performance review, new measure development, measure revision
• Identify and participate in research opportunities
• Work with Allison, Henrie, and the MPOG team
• Be able to devote 2 - 4 hours per month to this role
• Cardiac Subcommittee Vice-Chair Description: here
• Interested faculty should submit their interest to MPOG QI Director (Nirav Shah) at
nirshah@med.umich.edu and MPOG Cardiac Subcommittee Chair (Allison Janda) at
ajanda@med.umich.edu
Measure Review Process
• Review literature for given measure
topic and provide review using
MPOG Measure Review Template
• Present review of literature and
recommendations at Cardiac
Subcommittee meetings
• Reviewers names will be added to
measure specifications as well as
MPOG Measure Reviewer website
Upcoming Cardiac-Focused Measure Reviews
Measure Review Date Reviewers
TEMP-06-C: Hypothermia Avoidance March 2025 Mariya Geube, Cleveland Clinic
TEMP-07-C: Hyperthermia Avoidance March 2025 Ashan Grewal, UMaryland
GLU-06-C: Hyperglycemia Management June 2026 Josh Billings, Vanderbilt
GLU-07-C: Hypoglycemia Management June 2026 Rob Schonberger, Yale
GLU-08-C: Hyperglycemia Treatment June 2026 Josh Billings, Vanderbilt
Thank you in advance for ensuring MPOG Cardiac-specific measures remain relevant &
consistent with published recommendations!
Contact Allison with any questions: ajanda@med.umich.edu
Measure Review
TEMP-06-C Hypothermia Avoidance
Cardiac Anesthesia QI Subcommittee
March 14
th
, 2025
Mariya Geube, MD; Cleveland Clinic
Definition: Hypothermia avoidance
Percentage of adult patients undergoing an open cardiac procedure for whom any core
temperature at the end of the case < 35.5 C
Measure start at initiation of CPB
Measure end at 30 minutes after Anesthesia End
• Outcome metric
• Threshold : < 10%
Hypothermia avoidance
• Clinical rationale:
Perioperative hypothermia is defined as a core temperature < 36
degrees Celsius by the National Institute of Health and the American
Heart Association.
It can result in adverse effects including surgical site infections,
cardiovascular events, impaired wound healing and increased
hospital length of stay in both the non-cardiac and cardiac surgical
populations.
Such adverse effects are prevented through maintenance of
normothermia intraoperatively.
Hypothermia avoidance
• Assessment of current clinical rationale:
The literature is consistent regarding potential adverse effects of
hypothermia on major outcomes such as surgical wound infections,
increased length of hospital stay and cardiac adverse events
(postoperative MI)
In cardiac surgery, there is a strong support for normothermia in the
enhanced pathway algorithms, aiming to promote fast recovery and
early extubation. In addition, hypothermia may exacerbate
postoperative bleeding and delay recovery from neuromuscular
blockade.
Evaluation of inclusion and exclusion criteria
• Inclusion criteria:
Adult patients undergoing open cardiac surgery
• Exclusion criteria:
Noncardiac, transcatheter/endovascular/EP/Cath lab procedures
Appropriate
Measure source
• Temperature measurements are prioritized with hierarchy applied in the following
order:
• Bladder (core)
• Rectal (core)
• Blood (core) or PA catheter (core)
• Naso-pharyngeal (core)
• Esophageal (core)
• Zero flux thermometer (near core)
• Other non-core routes (axillary, oral, skin, temporal, tympanic)
Evaluation of definition of success and flagged cases
• Last core T within 30 minutes before Anesthesia End and after CPB end.
• Core T > 35.5 C 🡪 case passes
• Core T < 35.5 C 🡪 case flagged
• If no core T available 🡪 look for non-core T source
• If no T available within 30 minutes before Anesthesia End 🡪
Move to last core T within 30 minutes after Anesthesia End
• No T found 🡪 case flagged (T not documented)
Appropriate
Recommendation for Temp-06-C
Recommendation
Keep as is without changes ✔ Keep unchanged
Modify: specify changes
Retire: Eliminate entirely from
dashboard
Temp-06-C Hypothermia avoidance
01/01/2024 – 01/01/2025
60
%
1.National Collaborating Centre for N, Supportive C. National Institute for Health and Clinical Excellence:
Guidance.
The Management of Inadvertent Perioperative Hypothermia in Adults
. London: Royal College of
Nursing (UK)National Collaborating Centre for Nursing and Supportive Care.; 2008.
2. Yi J, Liang H, Song R, Xia H, Huang Y. Maintaining intraoperative normothermia reduces blood loss in
patients undergoing major operations: a pilot randomized controlled clinical trial.
BMC
anesthesiology.
2018;18(1):126.
3. Rajagopalan S, Mascha E, Na J, Sessler DI: The effects of mild perioperative hypothermia on blood loss and
transfusion requirement. Anesthesiology 2008; 108:71–7
4. 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
5. 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
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
7. 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
8. Karalapillai D, Story D, Hart GK, Bailey M, Pilcher D, Cooper DJ, Bellomo R: Postoperative hypothermia and
patient outcomes after elective cardiac surgery. Anaesthesia 2011; 66:780–4
9. Hannan EL, Samadashvili Z, Wechsler A, Jordan D, Lahey SJ, Culliford AT, Gold JP, Higgins RSD, Smith CR:
The relationship between perioperative temperature and adverse outcomes after off-pump coronary artery
bypass graft surgery. J Thorac Cardiovasc Surg 2010; 139:1568–75.e1
10. Hofer CK, Worn M, Tavakoli R, Sander L, Maloigne M, Klaghofer R, Zollinger A: Influence of body core
temperature on blood loss and transfusion requirements during off-pump coronary artery bypass grafting: a
comparison of 3 warming systems. J Thorac Cardiovasc Surg 2005; 129:838–43
Relevant New Literature
• Engelman et al. Guidelines for Perioperative Care in Cardiac Surgery: ERACS Recommendations
JAMA 2019
- Postoperative T > 36.0 C
• Grant et al. Perioperative Care in Cardiac Surgery: Expert Consensus Statement. Ann Thorac Surg
2024
- Postoperative T > 36.0 C included in the Surgical site infection prevention bundle
• Del Rio et al. Adult Cardiac Anesthesia Section of STS: 2020 Update on Quality and Outcomes
- Hypothermia not included. Data shown on most commonly used intraoperative T
sources
Relevant New Literature
• Sessler et al. Intraoperative warming vs routine thermal management during non-cardiac surgery:
PROTECT trial
- Superiority trial; active intraoperative warming group – T 37.1 C;
- Standard thermal management group – 35.6 C
- No difference in the 30 day composite cardiovascular outcomes
- Intraoperative T goal > 35.5 C enough for commonly cited complications
Relevant New Literature
• Shou et al. Impact of intraoperative blood products, fluids and persistent hypothermia on
reexploration for bleeding in cardiac surgery. J Thorac Cardiovasc Surg 2024
- Retrospective cohort ~ 4000 patients
- Re-exploration rate 3.7%
- Associations: Intraoperative crystalloid and postoperative hypothermia < 36.0 C
• Stuart et al. Perioperative Hypothermia in Robotic-Assisted Thoracic Surgery. J Thorac Cardiovasc
Surg 2024
- Retrospective cohort ~ 300 patients
- Factors associated with T < 35.5 C – age, low BMI, increased OR time
- Associated with higher surgical wound infections and pneumonia
TEMP-06-C: Hypothermia Avoidance, Cardiac
• Description:
– Percentage of adult patients undergoing an open cardiac surgery for whom any core
temperature at the end of the case was < 35.5
°
C (95.9
°
F)
• Timing:
– Measure start:
– Cardiopulmonary bypass initiated (ID:50410), if not present,
– Cardiopulmonary bypass start phenotype
– Measure end:
– 30 minutes after Anesthesia End
– *For cases without bypass: Anesthesia End 30 minutes after Anesthesia End
• Success:
– Last non-artifact body temperature > 35.5
°
C (95.9
°
F) at Anesthesia End (prioritizes
core temperature measurements)
TEMP-06-C: Hypothermia Avoidance, Cardiac
• Core Temperature Measurements will be prioritized over near-core temperature
measurements with hierarchy applied in the following order:
– Bladder (core)
– Rectal (core)
– Blood (core) or PA catheter (core)
– Nasal (core)
– Esophageal (core)
– Zero Flux thermometer (near core)
– Other non-core routes (axillary, oral, skin, temporal, tympanic)
TEMP-06-C: Performance Across MPOG
March 2024 - January 2025 (0 - 60%)
TEMP-06-C: Hypothermia Avoidance, Cardiac
1 vote/ site
Continue as is/ modify/ retire
Need > 50% to retire measure
Coordinating center will review all votes after meeting to ensure no
duplication
TEMP-07-C: Hyperthermia Avoidance, Cardiac
• Description:
– Percentage of adult patients undergoing an open cardiac surgery for whom core
temperature was > 37.5
°
C (99.5
°
F)
• Timing:
– Measure start:
– Cardiopulmonary bypass initiated (ID:50410), if not present,
– Cardiopulmonary bypass start phenotype
– Measure end:
– Cardiopulmonary bypass terminated (ID:50409), if not present,
– Cardiopulmonary bypass end phenotype, if not present
– Anesthesia End
• Success:
– Less than 5 consecutive minutes of non-artifact body temperature > 37.5
°
C (99.5
°
F) between
cardiopulmonary bypass start and cardiopulmonary bypass end (prioritizes core temperature
measurements)
TEMP-07-C: Hyperthermia Avoidance, Cardiac
• Core Temperature Measurements will be prioritized over near-core te measurements
with hierarchy applied in the following order:
– Arterial bypass cannula temperature (Concept ID:3263)
– Nasopharyngeal (Concept ID:3059)
– Esophageal (Concept ID:3055)
– Blood (Concept ID:3056) or keyword PA catheter
– Bladder (Concept ID:3058)
– Rectal(Concept ID:3061)
– Zero flux thermometer (non-core) via keyboard search of temperature routes
– Other non-core routes (axillary, oral, skin, temporal, tympanic, unspecified)
TEMP-07-C: Performance Across MPOG
March 2024 - January 2025 (0 - 100%)
TEMP-07-C: Dr. Grewal’s review
• No new literature/data found that would advise against goals of this measure
• No new data or guidelines found contradicting the rationale for the development of
this measure
• Measure includes all patients undergoing open cardiac surgical procedures requiring
CPB. This is in line with the goal and does not require modification.
• Logic correctly attributes to providers that are signed in for the greatest number of
minutes during CPB
TEMP-07-C: Dr. Grewal’s review
• The measure prioritizes arterial bypass cannula temperature measurement when
available. There is usually a differential between the arterial bypass cannula
temperature and the nasopharyngeal temperature (NPT) measurement, with NPT
possibly being lower. I wonder if the measure results for the sites that have the arterial
bypass cannula temperature measurement available would be different (more flagged
measurements) compared to NPT measurements.
• Overall Summary of Recommendations:
– Modify to analyze whether the sites with arterial bypass cannula temperature
measurement would have different measure results if nasopharyngeal temperature
(NPT) measurement was used. If so, then consideration should be given to
preferentially using NPT over arterial bypass cannula temperature.
TEMP-07-C: Hyperthermia Avoidance, Cardiac
1 vote/ site
Continue as is/ modify/ retire
Need > 50% to retire measure
Coordinating center will review all votes after meeting to ensure no
duplication
Measure Updates
AKI-02-C: Acute Kidney Injury, Cardiac
• Description:
– Percentage of adult patients undergoing open cardiac surgery with more than a 1.5x
increase in baseline creatinine within 7 postoperative days or the baseline creatinine
level increases by > 0.3 mg/dL within 48 hours postoperatively.
• Timing:
– Up to 7 days after Anesthesia End
• Success Criteria:
– The creatinine level does not go above 1.5x the baseline creatinine within 7 days postop
– The creatinine level does not increase by > 0.3 mg/dL obtained within 48 hours after
anesthesia end
• Recent updates:
– Increased measure threshold to < 20% from the original threshold of < 10%
– Update is live in QI Reporting Tool (dashboards) now!
AKI-02-C: Performance Across MPOG with < 20% threshold
March 2024 - January 2025 (0 - 100%)
ABX-03-C: Antibiotic Re-dosing, Open Cardiac Procedures
• Description:
– Percentage of adult patients undergoing open cardiac surgery with an antibiotic redose
initiated within four hours after initial antibiotic administration (cephalosporins only).
• Timing:
– 120 minutes prior to Anesthesia Start through Surgery End. If Surgery End is not
available, Anesthesia End
• Success Criteria:
– Documentation of cephalosporin redose within 165-255 minutes after each
cephalosporin administration
• Upcoming update:
– The measure will consider the most recent dose administered before surgical incision
start/ procedure start as initial dose
– Score changes were minimal (<1%)
– Update will reflect on your dashboard on April 7th
ABX-04-C: Antibiotic Selection, Open Cardiac Procedures
• Description:
– Percentage of adult patients undergoing open cardiac surgery with the
recommended antibiotic agents administered for surgical site infection
prophylaxis.
• Timing:
– 120 minutes prior to Anesthesia Start through Anesthesia End
• Success Criteria:
– Documentation of appropriate antibiotics administered preoperatively or
intraoperatively
ABX-04-C: Antibiotic Selection, Open Cardiac Procedures
Acceptable Antibiotics:
*Newly added antibiotics
Antibiotic Combinations for Open Cardiac Procedures
Vancomycin (ID: 10444) + Cephalosporin (IDs: 10106, 10107, 10108, 10109, 10110, 10111,
10112, 10113, 10114, 10115)
Vancomycin (ID: 10444) + Aminoglycoside (ID: 10202, 10023, 10433)
Vancomycin (ID: 10444) + Any gram negative (IDs: 10029, 10030, 10032, 10033, 10049, 10126,
10178, 10226, 10245, 10285, 10365, 10415)
Cephalosporin Only (IDs: 10106, 10107, 10108, 10109, 10110, 10111, 10112, 10113, 10114,
10115)
Antibiotics and Concepts
Aminoglycoside:
10023 Amikacin
10433 Tobramycin
Other gram negative:
10029 Amoxicillin
10030 Amoxicillin/Clavulanate
10032 Ampicillin
10033 Ampicillin/Sulbactam
10049 Aztreonam
10126 Ciprofloxacin
10178 Ertapenem
10226 Imipenem/Cilastatin
10245 Levofloxacin
10285 Meropenem
10365 Piperacillin/Tazobactam
10415 Sulfamethoxazole/Trimethoprim
ABX-04-C: Antibiotic Selection, Open Cardiac Procedures
Summary of changes:
• Upcoming update:
– Updated the rationale section for the measure to reflect the addition of
prophylactic gram negative antibiotics
– Added 2 new antibiotics to the Vancomycin + Aminoglycoside
combination
– Added a combination of Vancomycin + Any gram negative
• Score changes anticipated to be minimal for most sites. However, sites with a
primary regimen of Vanco + Gram negative antibiotic will see upwards of 25%
improvement in scores
• Change will reflect on your dashboard on April 7th
ABX-04-C: Antibiotic Selection, Open Cardiac Procedures
Question for the group:
• If there is documentation of ‘Patient on Scheduled Antibiotics, ’ should the case
be excluded or should we include and assess for appropriate antibiotics
administered?
– Finding cases where vancomycin + gram negative antibiotic administered but case is
excluded due to documentation of scheduled antibiotic.
Preliminary Measures
BP-07-C: Hypotension Avoidance (MAP < 55 mmHg),
Induction, Open Cardiac
• Description:
– Percentage of adult patients undergoing open cardiac procedures where
hypotension (defined as MAP < 55 mmHg) was avoided during the induction
period until surgery start.
• Timing:
– Anesthesia Start through Surgery Start
• Inclusions:
– Adult patients undergoing open cardiac procedures (determined by Procedure
Type: Cardiac value code: 1)
• Success Criteria:
– MAP > 55 mmHg throughout induction period until surgery start
BP-07-C: Hypotension Avoidance (MAP < 55 mmHg),
Induction, Open Cardiac
• Exclusions:
– Age < 18
– ASA 6 including Organ Procurement (CPT:01990)
– Non-cardiac, Transcatheter/Endovascular, EP/Cath, and Other Cardiac cases as
defined by the Procedure Type: Cardiac phenotype (value codes: 0, 2, 3, and 4)
– Lung transplants
Discussion
• Any questions or comments with this specification?
– Any duration thresholds?
• Any concerns with moving forward with BP-07-C?
• Should we move this to a vote?
– Yes
– No
TRAN-05-C: Coagulation Monitoring
Description:
– Percentage of adult patients undergoing open cardiac surgery who received
transfusion and had a TEG or ROTEM checked with administration of blood and/or
blood components
Timing:
– Anesthesia Start through Anesthesia End
Inclusions:
– Adult patients undergoing open cardiac procedures (determined by Procedure
Type: Cardiac value code: 1)
Success Criteria:
– TEG or ROTEM checked with administration of blood and blood components
TRAN-05-C: Coagulation Monitoring
Exclusions:
– Age < 18
– ASA 6 including Organ Procurement (CPT:01990)
– Patients who did not receive a transfusion
Transfusion defined as:
– Packed Red Blood Cells
– Whole Blood
– Fresh Frozen Plasma
– Cryoprecipitate
– Platelets
– Categorized Note - Blood Products
– Cases are excluded with only administration of autologous or salvaged blood
– Cases are included if autologous or salvaged blood is administered with any of the
above transfusions
Discussion
• Any questions or comments with this specification?
– Any ROTEM/TEG between anesthesia start and end or on the day of surgery?
– Considerations for how these labs are charted across all sites
• Any concerns with moving forward with TRAN-05-C?
• Vote?
– Yes, publish this measure
– No, give sites time to improve their mapping?
TRAN-06-C: Balanced Transfusion
Description:
– Percentage of adult patients undergoing open cardiac surgery who received
transfusion and a 1:1:1 ratio of blood products was administered
Timing:
– Anesthesia Start through Anesthesia End
Inclusions:
– Adult patients undergoing open cardiac procedures (determined by Procedure
Type: Cardiac value code: 1)
Success Criteria:
– 1:1:1 ratio of red blood cells to FFP to platelets were administered
TRAN-06-C: Balanced Transfusion
Questions/Concerns:
– Is a 1:1:1 ratio clinically superior to a laboratory-driven transfusion strategy?
Preliminary Data:
Seeking Cardiac Subcommittee Vice-Chair
• 2-year term
• Help shape direction of Cardiac Subcommittee
• Measure performance review, new measure development, measure revision
• Identify and participate in research opportunities
• Work with Allison, Henrie, and the MPOG team
• Cardiac Subcommittee Vice-Chair Description: here
