Variance in Therapy and Registry Variables

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3/17/216 Variance in Therapy and Registry Variables Lecture 5: AmSECT s Goal Directed Therapy Symposium Associate Professor Rob Baker, PhD Flinders Medical Centre and Flinders University Adelaide AUSTRALIA
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3/17/216 Variance in Therapy and Registry Variables Lecture 5: AmSECT s Goal Directed Therapy Symposium Associate Professor Rob Baker, PhD Flinders Medical Centre and Flinders University Adelaide AUSTRALIA DISCLOSURES Consultancy for Sorin Group in 215 Speaker at Goal Directed Perfusion Scientific Workshop, Berlin, Oct 215 ACKNOWLEDGEMENTS Richard Newland, BSc, CCP (Aus), Dip PERF Senior Perfusionist Flinders Medical Centre Project Manager Australian New Zealand Collaborative Perfusion Registry (ANZCPR) Data courtesy of the Australian & New Zealand Collaborative Perfusion Registry (ANZCPR). Not to be reproduced without permission 1 3/17/216 Outline What can influence the measurement and reporting of Goal Directed Perfusion Parameters? Share new evidence supporting monitoring of GDP parameters Where are we going and what data is already collected? An error does not become truth by reason of multiplied propagation, nor does the truth become error because nobody will see it. Mahatma Gandhi Young India Mahatma Gandhi Dr Rivers Goal directed therapy Bob Groom Goal Directed Perfusion Linda Mongero Electronic Data George Justison Developed the GDP story 2 3/17/216 Slides from PDUC DO2 talk Do you measure DO 2 during bypass? a) Yes, as a clinical indicator of adequacy of perfusion b) Yes, but it does not direct my clinical management c) No ARS a, b, or c Concerning Measuring DO 2 /DO 2i during bypass? a) Do you manually calculate DO 2i on pump? b) Do you use commercial software (CONNECT) to calculate DO 2i? c) Do you use commercial software (M4) to calculate DO 2i? d) Do you use in house software to calculate DO 2i on pump? e) Do not measure/calculate DO 2 during bypass. ARS choose one answer 3 3/17/216 Do you have any shunts in your circuit eg sampling line, arterial filter purge, oxygenator purge? a) None open during bypass? b) If yes, flow through shunt 1 ml/min c) If yes, flow through shunt 1-3 ml/min d) If yes, flow through shunt 31-5 ml/min e) If yes, flow through shunt 51 ml/min f) Yes but never measured the shunt flow ARS choose one answer Measuring flow for DO 2 i during bypass? a) Do you use roller pump to measure flow? b) Do you use flow probe with a roller pump to measure flow? c) Do you use flow probe with a centrifugal pump to measure flow? ARS choose one answer If you answered yes to having an open shunt during bypass? a) Is your flow measurement distal to any shunts you have in your circuit? ARS yes/no 4 12:3:13 12:5:33 12:7:54 12:1:14 12:12:35 12:14:55 12:17:16 12:19:36 12:21:56 12:24:17 12:26:37 12:28:57 12:31:18 12:33:38 12:35:59 12:38:19 12:4:4 12:43: 12:45:2 12:47:41 12:5:1 12:52:21 12:54:42 12:57:2 12:59:23 13:1:43 13:4:4 12:3:13 12:5:33 12:7:54 12:1:14 12:12:35 12:14:55 12:17:16 12:19:36 12:21:56 12:24:17 12:26:37 12:28:57 12:31:18 12:33:38 12:35:59 12:38:19 12:4:4 12:43: 12:45:2 12:47:41 12:5:1 12:52:21 12:54:42 12:57:2 12:59:23 13:1:43 13:4:4 3/17/216 Error in DO Oxygen Delivery 2i (flow 4.5, Hb 9, Sat 99, PaO 2 2, BSA 2) DO of about 2 i 4 ml/min/m 2 Ranucci 25 DeSomer & Ranucci 211 Oxygen delivery (DO 2 i) GDP formula: DO 2 i = (Flow * (Hct/2.94 * 1.36 * SaO 2 ) + PaO 2 *.3) * 1) / BSA DO2i GDP S5 1 Oxygen delivery (DO 2 i) GDP formula: DO 2 i = (Flow * (Hct/2.94 * 1.36 * SaO 2 ) + PaO 2 *.3) * 1) / BSA 6 Flow Sensor vs Roller Pump DO2i GDP M4 DO2i GDP S5 1 5 Flow L/min 12:3:13 12:5:33 12:7:54 12:1:14 12:12:35 12:14:55 12:17:16 12:19:36 12:21:56 12:24:17 12:26:37 12:28:57 12:31:18 12:33:38 12:35:59 12:38:19 12:4:4 12:43: 12:45:2 12:47:41 12:5:1 12:52:21 12:54:42 12:57:2 12:59:23 13:1:43 13:4:4 12:3:13 12:5:33 12:7:54 12:1:14 12:12:35 12:14:55 12:17:16 12:19:36 12:21:56 12:24:17 12:26:37 12:28:57 12:31:18 12:33:38 12:35:59 12:38:19 12:4:4 12:43: 12:45:2 12:47:41 12:5:1 12:52:21 12:54:42 12:57:2 12:59:23 13:1:43 13:4:4 3/17/216 Oxygen delivery (DO 2 i) GDP formula: DO 2 i = (Flow * (Hct/2.94 * 1.36 * SaO 2 ) + PaO 2 *.3) * 1) / BSA Shunts 6 5 Roller 4 Flow: DO 2 i 291 Flow distal to shunt (3): DO 2 i Flow distal to shunt (7): DO 2 i DO2i GDP M4 DO2i GDP S5 1 Oxygen delivery (DO 2 i) GDP formula: DO 2 i = (Flow * (Hct/2.94 * 1.36 * SaO 2 ) + PaO 2 *.3) * 1) / BSA Tubing 7 HL2 Flow Evaluation S5/SCP/M Physio Physio Smart Smart S5 SCP M4 Art Flow M4 Ven Flow 2 Oxygen delivery (DO 2 i) GDP formula: DO 2 i = (Flow * (Hct/2.94 * 1.36 * SaO 2 + PaO 2 *.3) * 1) / BSA M4 formula: DO 2 i = (Flow * Hb* 1.34 * SaO 2 * 1) / BSA DO2i GDP DO2i M 3/17/216 Slides from PDUC DO2 talk Do you routinely measure exhaust CO 2 during bypass? a) Yes b) No ARS yes/no If you do, how do you routinely measure exhaust CO 2 during bypass? a) Dedicated capnograph to measure ExhCO 2? b) Use the anaesthetic machine capnograph to measure ExhCO 2? c) Use a M4 to measure ExhCO 2? d) Other device ARS choose one answer 7 12:3:13 12:5:13 12:3:13 12:7:13 12:5:13 12:9:14 12:7:13 12:11:15 12:9:14 12:13:14 12:11:15 12:15:15 12:13:14 12:17:16 12:15:15 12:17:16 12:19:15 12:19:15 12:21:16 12:21:16 12:23:17 12:23:17 12:25:17 12:25:17 12:27:17 12:27:17 12:29:17 12:29:17 12:31:18 12:31:18 12:33:18 12:33:18 12:35:18 12:35:18 12:37:19 12:37:19 12:39:19 12:39:19 12:41:19 12:41:19 12:43:2 12:43:2 12:45:2 12:45:2 12:47:2 12:47:2 12:49:21 12:49:21 12:51:21 12:51:21 12:53:22 12:53:22 12:55:22 12:55:22 12:57:23 12:57:23 12:59:23 12:59:23 13:1:23 13:1:23 13:3:24 13:3:24 3/17/216 Do you routinely measure PaCO 2 and PvCO 2? a) Yes b) No ARS yes/no Oxygenator CO 2 monitoring mmhg M4 FeCO2 M4 FiCO2 VamosCO2 1 5 % CO 2 production (VCO 2 i) GDP formula: VCO 2 i = (Gas flow * CO2exh * 1.15) / BSA GDP VCO2i VCO2iM 12:3:13 12:3:13 12:3:13 12:5:13 12:5:13 12:5:13 12:7:13 12:7:13 12:7:13 12:9:14 12:9:14 12:9:14 12:11:15 12:11:15 12:11:15 12:13:14 12:13:14 12:13:14 12:15:15 12:15:15 12:15:15 12:17:16 12:17:16 12:17:16 12:19:15 12:19:15 12:19:15 12:21:16 12:21:16 12:21:16 12:23:17 12:23:17 12:23:17 12:25:17 12:25:17 12:25:17 12:27:17 12:27:17 12:27:17 12:29:17 12:29:17 12:29:17 12:31:18 12:31:18 12:31:18 12:33:18 12:33:18 12:33:18 12:35:18 12:35:18 12:35:18 12:37:19 12:37:19 12:37:19 12:39:19 12:39:19 12:39:19 12:41:19 12:41:19 12:41:19 12:43:2 12:43:2 12:43:2 12:45:2 12:45:2 12:45:2 12:47:2 12:47:2 12:47:2 12:49:21 12:49:21 12:49:21 12:51:21 12:51:21 12:51:21 12:53:22 12:53:22 12:53:22 12:55:22 12:55:22 12:55:22 12:57:23 12:57:23 12:57:23 12:59:23 12:59:23 12:59:23 13:1:23 13:1:23 13:1:23 13:3:24 13:3:24 13:3:24 3/17/216 CO 2 production (VCO 2 i) GDP formula: VCO 2 i = (Gas flow * CO2exh mmhg * 1.15) / BSA M4 formula: VCO 2 i = (Gas flow * (FeCO2-FiCO2 (%)) * 1) / BSA GDP VCO2i VCO2iM4 4 2 CO 2 production (VCO 2 i) GDP formula: VCO 2 i = (Gas flow * CO2exh mmhg * 1.15) / BSA M4 formula: VCO 2 i = (Gas flow * (FeCO2-FiCO2 (%)) * 1) / BSA GDP VCO2i VCO2iM4 4 2 CO 2 production (VCO 2 i) GDP formula: VCO 2 i = (Gas flow * CO2exh mmhg * 1.15) / BSA M4 formula: VCO 2 i = (Gas flow * (FeCO2-FiCO2 (%)) * 1) / BSA GDP VCO2i VCO2iM 3/17/216 In-vitro oxygenator comparison Calculation of VCO 2 requires measurement of CO 2 concentration in the oxygenator exhaust gas Accuracy may be limited by; design of the oxygenator measurement device used alterations in the exhaust gas flow Aim: Compare the measurement of CO 2 concentration in the oxygenator exhaust gas using 2 different capnographs and an exit CO 2 sensor, in 5 (2/3) different oxygenators. In-vitro oxygenator comparison RX (Terumo) Inspire (LivaNova) Fusion (Medtronic) FX (Terumo) Compactflo (Dideco) 1 1:42:18 1:42:58 1:43:38 1:44:18 1:44:58 1:45:38 1:46:18 1:46:58 1:55:2 1:56: 1:56:39 1:57:2 1:57:59 1:58:4 1:59:2 1:47:18 1:47:58 1:48:39 1:49:18 1:49:59 1:5:39 1:51:19 1:51:59 11::2 11:1: 11:1:4 11:2:2 11:3:1 11:3:4 11:4:21 3/17/216 In-vitro oxygenator comparison Primed with Plasmalyte solution and expired donor blood added (Hb 8 g/dl) CO 2 titrated to achieve an arterial pco mmhg Drager scavenging device attached to the M4 gas module with wall suction applied to provide passive collection of exhaust gas Vamos and Datex capnographs connected via sampling tubing immediately distal to the M4 exit gas sensor 3/8 luer connector utilised to enable measurements to be obtained with the scavenging system vented (luer cap off) or non vented (luer cap on) M4 exhaust gas sensor To capnograph Oxygenator exhaust To wall suction Water trap In-vitro oxygenator comparison: CO 2 monitoring 25 Terumo RX 2 15 M4pCO2 GDP_DO2i 1 Non Vented Vented RX GDP-VCO2i FeCO2 VamosCO2 M4DO2i 5 11 15:15:2 15:16:22 15:17:42 15:19:2 15:22:3 15:23:23 15:24:43 15:26:4 15:27:44 15:29:4 15:3:24 15:31:44 15:35:5 15:36:25 15:37:45 13:38:7 13:39:27 13:4:47 13:42:7 13:49:28 13:5:48 13:52:8 13:53:28 13:43:47 13:45:7 13:46:27 13:47:47 13:55:8 13:56:28 13:57:48 17:9:3 17:1:23 17:11:43 17:13:3 17:18:24 17:19:45 17:21:5 17:22:25 17:24:25 17:25:46 17:27:6 17:28:27 17:3:27 17:31:48 17:33:7 16:15:14 16:16:54 16:18:34 16:2:34 16:22:15 16:23:55 16:25:36 16:27:36 16:29:16 16:3:56 16:33:37 16:35:17 16:36:58 3/17/216 Terumo FX Dideco CompactFlo M4pCO2 M4pCO2 15 GDP_DO2i 15 GDP_DO2i 1 FX GDP-VCO2i 1 CF GDP-VCO2i FeCO2 FeCO2 5 VamosCO2 5 VamosCO2 M4DO2i M4DO2i Medtronic Fusion LivaNova Inspire M4pCO2 GDP_DO2i 2 15 M4pCO2 GDP_DO2i 1 5 F GDP-VCO2i FeCO2 VamosCO2 1 5 INS GDP-VCO2i FeCO2 VamosCO2 M4DO2i M4DO2i Outline What can influence the measurement and reporting of Goal Directed Perfusion Parameters? Share novel supporting evidence for monitoring of GDP parameters Where are we going and what data is already collected? Critical Care 26; 1:R167 N=47 Peak arterial blood lactate levels according to the cardiopulmonary bypass duration. Data are shown as rolling deciles (75% overlapping). Symbols (open boxes) represent the mean value recorded for each decile. 12 3/17/216 Critical Care 26; 1:R167 N=47 N=12,397 Peak arterial blood lactate value during cardiopulmonary bypass (CPB) according to the CPB duration. The plot shows the cubic spline values, calculated as the medians of both variables at equal time intervals. Data courtesy of the Australian & New Zealand Collaborative Perfusion Registry (ANZCPR). Not to be reproduced without permission Blood glucose & lactate N=47 Peak arterial blood lactate levels according to the peak blood glucose levels. Data are shown as rolling deciles (75% overlapping). Symbols (open boxes) represent the mean value recorded for each decile. Blood glucose & lactate N=12,397 N=47 Peak arterial blood lactate value during cardiopulmonary bypass (CPB) according to the peak blood glucose value. The plot shows the cubic spline values, calculated as the medians of both variables at equal blood glucose intervals. Data courtesy of the Australian & New Zealand Collaborative Perfusion Registry (ANZCPR). Not to be reproduced without permission 13 3/17/216 Oxygen delivery & lactate N=47 Peak arterial blood lactate levels according to the lowest oxygen delivery. Data are shown as rolling deciles (75% overlapping). Symbols (open boxes) represent the mean value recorded for each decile. Oxygen delivery & lactate N=12,397 N=47 Peak arterial blood lactate value during cardiopulmonary bypass (CPB) according to the lowest oxygen delivery. The plot shows the cubic spline values, calculated as the medians of both variables at DO 2i intervals. Data courtesy of the Australian & New Zealand Collaborative Perfusion Registry (ANZCPR). Not to be reproduced without permission Look at lowest oxygen delivery: leveraging electronic data 14 3/17/216 Min Hb Min Hb Outline What can influence the measurement and reporting of Goal Directed Perfusion Parameters? Share new evidence supporting the role of GDP Where are we going and what data is already collected? 15 AKI /17/216 Data courtesy of the Australian & New Zealand Collaborative Perfusion Registry (ANZCPR). Not to be reproduced without permission Lowess smoother AUC bandwidth =.8 Indicates an increase in probability of AKI for AUC values (greater proportion of CPB with DO 2 27 ml/min/m 2 ). Results: AUC above or below 27 ml/min/m 2 Calculated parameters utilising data obtained from the Spectrum M4 AUC + (n=89) AUC - (n=121) p Received RBC transfusion 8% 38% .1 Acute kidney injury 7% 2%.7 Average DO 2 i, l/min/m (24) 228 (28) .1 AUC DO 2 i, 27 l/min/m ( ) -38 ( ) .1 Nadir DO 2 i/vco 2 i 4.4 (9.5) 3.6 (2.2) 3/17/216 Results: AUC above or below 27 ml/min/m 2 Calculated parameters utilising data obtained from the Spectrum M4 AUC + (n=89) AUC - (n=121) p Received RBC transfusion 8% 38% .1 Acute kidney injury 7% 2%.7 Average DO 2 i, l/min/m (24) 228 (28) .1 AUC DO 2 i, 27 l/min/m ( ) -38 ( ) .1 Nadir DO 2 i/vco 2 i 4.4 (9.5) 3.6 (2.2).817 Results: AUC above or below 27 ml/min/m 2 Calculated parameters utilising data obtained from the Spectrum M4 AKI (n=3) No AKI (n=181) p Nadir* CPB hct, g/l 25 (4) 27 (4).2 Nadir* DO 2 i, l/min/m 2 17 ( ) 18 (147-21).8 Nadir* DO 2 i, l/min/m (4) 261 (42).1 AUC DO 2 i, 27 l/min/m ( ( ) 1835) Nadir* DO 2 i/vco 2 i 3.2 (3) 4.2 (7.8).258 Challenged our interpretation of VCO2 i data Avg GDP VCO 2i = 52 Avg M4 VCO 2i = 92 GDP: If DO 2i = 27, VCO 2i = 54 DO 2i /VCO 2i = 5 However with M4 data, If DO 2i = 27, and VCO 2i = 94 DO 2i /VCO 2i = 3/17/216 Definition and calculation of GDP parameters Consensus needed on how we define lowest GDP parameters in data analysis; What is the lowest Hb, po 2, VCO 2? Should we use intermittent or continuous blood gas data Howe do we define the lowest flow during CPB using continuous data? How do we time weight lowest values?; What is the critical time value for each GDP parameter threshold? Electronic Data Acquisition into the EMR Unlimited potential Commercial systems LivaNova CONNECT/GDP Spectrum M4 Terumo CDI-5 Need to know the equipment Raw data or transformed Value of point estimates Manually or electronically calculated Registry Data ANZCPR The raw data we collect allows us to calculate a DO 2 for every case Depending on what you need Transformed or raw data DO 2 i, VCO 2 i, VO 2 i Need common definitions, time periods Flow, Hb, p a O 2, p v O 2, p a CO 2, p v CO 2, S a O 2, S v O 2, S a CO 2, S v CO 2, FiCO2, FeCO2, exhaust capnography 18 3/17/216 Defining minimum DO 2i? Measurement Ranucci et al DeSomer et al ANZCPR Formula Lowest HCT Measured every 2 min Devices Arterial oxygen tension Recorded simultaneously to lowest HCT Defining NADIR Measured every 1 min As per institutional protocol Recorded simultaneously to lowest HCT Lowest recorded during CPB Cardiac index Mean value during 3 minutes of CPB around the time when the lowest HCT was recorded Recorded simultaneously to lowest HCT Average CPB cardiac index Slides from PDUC DO2 talk Thank you Measurement is the first step that leads to control and eventually to improvement. If you can t measure something, you can t understand it. If you can t understand it, you can t control it. If you can t control it, you can t improve it. H. James Harrington Quality/Improvement/Business H. James Harrington 19
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