Cardiac Anesthesia Subcommittee Minutes

March 14, 2025

1:00pm – 2:00pm EST

Zoom

Addo, Henrietta (MPOG)

LaLonde, Heather (Trinity Health)

Atwood, Tammy (Henry Ford)

Lopacki, Kayla (Trinity Health)

Barrios, Nicole (MPOG)

Malenfant, Tiffany (MPOG)

Bartoszko, Justyna (Toronto)

McCaughan, Michael (Sparrow)

Benitez, Julio (Sparrow)

Mathis, Mike (MPOG)

Bow, Peter (Michigan)

Mirizzi, Kam (MPOG)

Brown, Morgan (Boston Children's)

O'Conor, Katie (Johns Hopkins)

Buehler, Kate (MPOG)

Notorianni, Andrew (Yale)

Calabio, Mei (MPOG)

O'Dell, Diana (MPOG)

Cassidy, Ruth (MPOG)

Nugele, Judy, Trinity Health)

Corpus, Charity (Corewell Health)

Pennington, Bethany (WUSTL)

Crimi, Ettore (Wake Forest)

Shah, Nirav (MPOG)

Coleman, Robert (MPOG)

Smiatacz, Frances Guida (MPOG)

Delhey, Leanna (MPOG)

Steinhorn, Rachel (Mass Gen)

Geube, Mariya (Cleveland)

Stumpf, Rachel (MPOG)

Gebhardt, Brian (UMass)

Sturmer, David (Michigan)

Guruswamy, Jayakar (Jay) (Henry Ford)

Tabbara, Abdo (Henry Ford)

Janda, Allison (MPOG)

Weinberg, Aaron (Weill Cornell)

Kinney, Daniel (Yale)

Meeting Start: 1302

1. Agenda

a. Introduction & announcements

b. Measure Reviews:

i. TEMP-06-C: Hypothermia Avoidance, Cardiac

ii. TEMP-07-C: Hyperthermia Avoidance, Cardiac

c. Measures Updates:

i. AKI-02-C: Acute Kidney Injury, Cardiac

ii. ABX-03-C: Antibiotic Re-dosing, Open Cardiac

iii. ABX-04-C: Antibiotic Selection, Open Cardiac

d. Preliminary Data for New Measure:

i. BP-07-C: Hypothermia Avoidance, Induction, Open Cardiac (MAP < 55 mmHg)

ii. TRAN-05-C: Coagulation Monitoring

e. Summary and Next Steps

2. Introductions

a. ASPIRE Quality Team

i. Allison Janda, MD – MPOG Cardiac Anesthesia Subcommittee Lead

ii. Michael Mathis, MD – MPOG Director of Research

iii. Henrietta Addo, MSN, RN – Quality Improvement Specialist

b. Cardiac Anesthesiology Representatives joining us from around the US!

3. Seeking Cardiac Subcommittee Vice-Chair

a. 3 – year term

b. Help shape direction of Cardiac Subcommittee

c. Measure performance review, new measure development, measure revision

d. Identify and participate in research opportunities

e. Work with Allison, Henrie, and the MPOG team

f. Be able to devote 2 – 4 hours per month to this role

g. Cardiac Subcommittee Vice-Chair Description: here

h. 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

4. Measure Review Process

a. Review literature for given measure topic and provide review using MPOG Measure

Review Template

b. Present review of literature and recommendations at Cardiac Subcommittee meetings

c. Reviewers' names will be added to measure specifications as well as MPOG Measure

Reviewer website

5. 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

a. Thank you in advance for ensuring MPOG Cardiac-specific measures remain relevant &

consistent with published recommendations

b. Contact Allison with any questions: ajanda@med.umich.edu

5. Measure Review

a. TEMP-06-C: Hypothermia Avoidance, Cardiac – Mariya Geube, MD, Cleveland Clinic

i. 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)

ii. Timing:

(a) Measure start:

1. Cardiopulmonary bypass initiated (ID:5410), if not present,

2. Cardiopulmonary bypass start phenotype

(b) Measure End:

1. 30 minutes after Anesthesia End

2. For cases without bypass: Anesthesia End 30 minutes after

Anesthesia End

iii. Success: Last non-artifact body temperature > 35.5 °C (95.9 °F) at Anesthesia

End (prioritizes core temperature measurements)

iv. Core temperature measurements will be prioritized over near-core temperature

measurements with hierarchy applied in the following order:

(a) Bladder (Core)

(b) Rectal (Core)

(d) Nasal (Core)

(e) Esophageal (Core)

(f) Zero Flux Thermometer (Near core)

(g) Other non-core routes (axillary, oral, skin, temporal, tympanic)

v. Additional references:

(a) Engelman et al. Guidelines for Perioperative Care in Cardiac

Surgery: ERACS Recommendations JAMA 2019

(b) Grant et al. Perioperative Care in Cardiac Surgery: Expert

Consensus Statement. Ann Thoracic Surg 2024

Update on Quality and Outcomes

(d) Sessler et al. Intraoperative warming vs routine thermal

management during non-cardiac surgery: PROTECT Trial

(e) Shout et al. Impact of intraoperative blood products, fluids and

persistent hypothermia on reexploration for bleeding in cardiac surgery.

(f) Stuart et al. Perioperative Hypothermia in Robotic-Assisted

Thoracic Surgery

vi. Discussion:

vii. Mike Mathis (UMichigan): Reasonable to keep at 35.5 rather than increasing the

bar to 36.0 Celsius.

viii. Mariya Geube (Cleveland Clinic): Recommend keeping measure defined as

<35.5°Celsius rather than 36.0

ix. Bethany Pennington (WashU): What is the most common reason for flagged

cases: not having a temperature or for being <35.5?

(a) Allison Janda (MPOG Coordinating Center): Was actually due to

patients being hypothermic rather than just not getting a temperature

at the end of the case.

x. Vote:

(a) 1 vote/site

(b) Continue as is / modify to <36.0°Celsius / retire

(d) Coordinating Center will review all votes after meeting to

ensure no duplication

xi. Next Steps:

(a) Continue as is with the addition of a breakdown of flagged cases

to QIRT for # of cases without a temperature vs. # of cases flagged for

hypothermia

b. TEMP-07-C: Hyperthermia Avoidance, Cardiac – Ashan Grewal, University of Maryland

i. Description: Percentage of adult patients undergoing an open cardiac surgery

for whom core was > 37.5 °C (99.5 °F)

ii. Timing:

(a) Measure Start:

1. Cardiopulmonary bypass initiated (ID:54010), if not present,

2. Cardiopulmonary bypass start phenotype

(b) Measure End:

1. Cardiopulmonary bypass terminated (ID:50409), if not present,

2. Cardiopulmonary bypass end phenotype, if not present

3. Anesthesia End

iii. Success: Less than 5 consecutive minutes of non-artifact temperature > 37.5 °C

(99.5 °F) between cardiopulmonary bypass start and cardiopulmonary bypass

end (prioritizes core temperature measurements)

iv. Core temperature measurements will be prioritized over near-core temperature

measurements with hierarchy applied in the following order:

(a) Arterial bypass cannula temperature (Concept ID:3263)

(b) Nasopharyngeal (Concept ID:3059)

(d) Blood (Concept ID:3056) or keyword PA catheter

(e) Bladder (Concept ID:3058)

(f) Rectal (Concept ID:3061)

(g) Zero Flux thermometer (non-core) via keyboard search of

temperature routes

(h) Other non-core routes (axillary, oral, skin, temporal, tympanic,

unspecified)

v. Discussion:

(a) Ashan Grewal (UMaryland) Recommendation: Consider

prioritizing nasopharyngeal route over arterial bypass cannula

temperature measurement when available.

(b) Tammy Atwood (Henry Ford Allegiance): Our guidelines

recommend not allowing temperatures >37.0 for arterial cannula route

anyways.

accurate vs. most common across sites. Do we want to prioritize more

accurate vs. most common route? I would lean towards the most

accurate route rather than most used.

(d) Bethany Pennington (WashU) via chat: Does this impact the

majority of sites or just a few?

vi. Vote:

(a) 1 vote/site

(b) Continue as is / modify the route algorithm to prioritize

nasopharyngeal over arterial bypass cannula/ retire

(d) Coordinating Center will review all votes after meeting to

ensure no duplication

vii. Next Steps:

(a) Continue as is with an updated breakdown of flagged cases to

show # of cases with route: nasopharyngeal source vs. arterial bypass

cannula source for temperature.

6. Measure Updates:

1. AKI-02-C: Acute Kidney Injury in patients undergoing Open Cardiac Surgery

(reported as an inverse measure)

i. Description: Percentage of adult patients undergoing open cardiac

surgery with more than 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

ii. Timing: up to 7 days after Anesthesia End

iii. Success Criteria:

1. The creatinine level does not go above 1.5x the baseline

creatinine within 7 days postop

2. The creatinine level does not increase by > 0.3 mg/dL

within 48 hours after anesthesia end

iv. Change:

1. Increased measure threshold to < 20% from the original

threshold of < 10%

2. Update is live in QI Reporting Tool (dashboards) now!

2. ABX-03-C: Antibiotic Re-dosing, Open Cardiac

i. Description: Percentage of adult patients undergoing open cardiac surgery

with an antibiotic re-dose initiated within 3-4 hours after initial antibiotic

administration (cephalosporins only)

ii. Timing: 120 minutes prior to Anesthesia Start through Surgery End. If

Surgery End is not available, then Anesthesia End.

iii. Success Criteria: Documentation of cephalosporin re-dose within 165-255

minutes after each cephalosporin administration (max: 3 doses)

iv. Upcoming updates:

1. The measure will consider the most recent dose administered

before surgical incision start/procedure start as the initial dose

2. Score changes were minimal

3. Update will reflect on your dashboard on April 7th

3. ABX-04 Antibiotic Selection, Open Cardiac Procedures

i. Description: Percentage of adult patients undergoing open cardiac surgery

with the recommended antibiotic agents administered for surgical site

infection prophylaxis

ii. Timing: 120 minutes prior to Anesthesia Start through Anesthesia End

iii. Success Criteria: Documentation of appropriate antibiotics administered

preoperatively or intraoperatively

iv. Acceptable antibiotic combinations for Open Cardiac Procedures:

1. Vancomycin + Cephalosporin

2. Vancomycin + Aminoglycoside

3. Vancomycin + Any gram negative

4. Cephalosporin Only

v. Cases will be assigned one of the following result reasons:

1. Passed – Vancomycin + Cephalosporin

2. Passed – Vancomycin + Aminoglycoside

3. Passed – Vancomycin + Any gram negative

4. Passed – Cephalosporin Only

5. Flagged – Non-standard antibiotic selection

6. Flagged – Prophylactic antibiotic not administered (Not

documented in MAR)

7. Flagged – Antibiotic not ordered/indicated per surgeon

8. Flagged – Not administered for medical reasons

9. Excluded – Scheduled antibiotics/documented infection

vi. Summary of changes:

1. Updated the rationale section of the measure to reflect the addition

of prophylactic gram-negative antibiotics

2. Added 2 new antibiotics to the Vancomycin + Aminoglycoside

combination

3. Added a combination of Vancomycin + Any gram negative

4. Score changes anticipated to minimal for most sites. However, sites

with a primary regimen of Vanco + gram negative antibiotic will see

upwards of 25% improvement in scores

5. Change will reflect on your dashboard on April 7

vii. Questions for the group:

1. If there is documentation of ‘Patient on Scheduled Antibiotics,’

should the case be excluded or should we include and assess for

appropriate antibiotics administered?

a. Finding cases were Vancomycin + gram negative antibiotic

administered by case is excluded due to documentation of

scheduled antibiotic.

2. Discussion:

a. Micheal Mathis: Keep them excluded

b. Mariya Geube via chat: Keep them excluded

Preliminary Measures

1. BP-07-C: Hypotension Avoidance (MAP < 55 mmHg), Induction, Open Cardiac

i. 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

ii. Timing: Anesthesia Start through Surgery Start

iii. Inclusions: Adult patients undergoing open cardiac procedures (determined

by Procedure Type: Cardiac value code:1)

iv. Success criteria: MAP >/= 55 mmHg throughout induction period until

surgery start

v. Exclusions:

i. Age < 18

ii. ASA 6 including Organ Procurement (CPT:01990)

iii. 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)

iv. Lung transplants

vi. Discussion:

i. Any questions or comments with this specification?

1. Any duration thresholds?

ii. Any concerns with moving forward with BP-07-C?

iii. Should we move this to a vote?

vii. Vote

viii. Next steps:

i. Set duration of MAP < 55mmHg to 5 or 10 minutes

ii. Proceed with measure spec development

Next Steps:

1. Open to all anesthesiologists or those interested in improving cardiothoracic

measures

a. Do not have to practice at an active MPOG institution

2. Meeting schedule:

a. June 2025

b. November 2025

3. Thank you for using the forum for discussion between meetings

Meeting adjourned: 1403