Michigan STS Data Managers Meeting - MSTCVSensues, requiring intubation, and pericardiocentesis. Inotropes are started with no improvement in hemodynamics. The patient is immediately

Michigan STS Data Managers Meeting

August 11, 2016Boyne Mountain Resort

Up North, MI

Present SM in a slightly different format to promote “The Big Picture” scenario.

Expose Newer DM’s to Instructional Clinical Scenarios…30% of our DM’s have less than 1 year of experience. Some have no OR exposure.

Help to achieve statewide consensus by promoting discussion and exchange.

Reading the Scenario is necessary as the format has changed from previous survey’s.

Thank You to those that responded!!

Please provide feedback regarding this format in your evaluations!

Rather than multiple scenarios, all questions are based on a single scenario to mimic chart abstraction.

A 66 yo homeless male presents to the ER @ 8:00 pm. with unrelenting chest pain unlike any he has ever experienced before. He is hypotensive (BP in 70's), diaphoretic, ashen, agitated, and is demonstrating non-specific EKG changes. Unable to obtain an accurate H&P, and suspecting ACS, the patient is given ASA and Plavix, the STEMI team is notified, and he is taken directly to the Cath Lab. Imaging reveals normal coronary arteries, but identifies a 6 cm. ascending aorta, severe AI, "Severe" LV dysfunction, and pericardial tamponade. Further hemodynamic instability ensues, requiring intubation, and pericardiocentesis. Inotropes are started with no improvement in hemodynamics. The patient is immediately taken to the OR @ 9:15 pm. with a diagnosis of Aortic Dissection. Once on CPB, the surgeon discovers that the dissection originates in the ascending aorta, and extends past the aortic arch. The operation involves replacing the aortic valve with a 21mm bioprosthetic device sewn into a synthetic graft, attached distally at the Hemi-Arch, and re-implantation of the coronary ostia.

Patient ScenarioPart 1

Question 1 Selections:

Prior MI = Yes (<=6 hrs.); Risk Factor's = Thoracic Dz; Pre-Op Meds = ASA + ADP Inhibitor + Inotropes; Cardiac Presentation at Surgery = STEMI.

Prior MI = No; Risk Factor's = Thoracic Aorta Dz; Pre-Op Meds = ADP Inhibitor + Inotropes; Cardiac Presentation at Surgery = Other.

Prior MI = Yes (<=6 hrs.); Risk Factor's = Unknown; Pre-Op Meds = ADP Inhibitor + Inotropes; Cardiac Presentation at Surgery = NSTEMI.

Points to Consider

Did the Patient have an MI?

What are his Risk Factor’s?

What Pre-Op Meds were administered?

What is the Presentation at Surgery?

Points to ConsiderDid the Patient have an MI?




No Cardiac Biomarker documentation “Non-Specific” EKG only

No prior history available

Points to Consider

Did the Patient have an MI?




Thoracic Dz. is only documented Risk Factor

Documented: ASA, ADP Inhibitor, Inotropes

NSTEMI, STEMI, Other

A patient presents for valve surgery with CHF, and no pain. Code other since the field is intended to capture cardiac presentation.

Training Manual Examples for “Other”

Patient does not need to be in active CHF to use “Other” as the cardiac presentation answer!

Survey says…..

Prior MI = YesRF’s = Thoracic DzMeds = ASA+ADP+InotropesCard Present = STEMI

Prior MI = NoRF’s = Thoracic DzMeds = ADP+InotropesCard Present = Other

Prior MI =YesRF’s = UnknownMeds = ADP+InotropesCard Present = NSTEMI

Question 2 Selections:Previous Cardiac Intervention = Yes, Other Cardiac, Other; Heart Failure w/in 2 wks. = No; Cardiogenic Shock = Yes; Aortic Disease = Yes, Symptomatic, Hemodynamics Unstable.Previous Cardiac Intervention = Yes, Other Cardiac, Other; Heart Failure w/in 2 wks. = Yes, NYHA IV; Cardiogenic Shock = Yes; Aortic Disease = Yes, Location = Ascending.Previous Cardiac Intervention = No; Heart Failure w/in 2 wks. = No, Cardiogenic Shock = Yes; Aortic Disease = Yes, Lesion Type = Dissection.

Points to Consider

Were there Previous Cardiac Interventions?

Was there Heart Failure w/in 2 weeks?

Was the Patient in Cardiogenic Shock?

Aortic Disease: Presentation, Location, and Lesion Type?

No documented Previous Interventions other than Pericardiocentesis in Cath Lab.

Previous Cardiac Interventions

Pericardiocentesis is not a listed option for (#805) except for Other Cardiac (not listed).

Cardiac Tamponade

Points to Consider




Aortic Disease: Presentation, Location, and Lesion Type? Pericardiocentesis = Gray Area No consensus at the National level What is the Michigan consensus?

?

Heart Failure w/in 2 weeks

Points to Consider





? Based on scenario,the patient does not fit the clinical

picture of HF No physician documented HF

Cardiogenic Shock

Sustained hypotension (BP 70’s) Inotropic support required.

Points to Consider





?

Meets the clinical definition of Cardiogenic Shock

Aortic Disease

Presentation (most severe): Pain, hypotension, inotropes =Symptomatic, Hemodynamically Unstable.

Location (Choose all that apply): Where is the lesion present? Ascending Aorta, Aortic Arch.

Lesion Type: Dissection Timing: Acute Dissection Type: Stanford “Type A” aka: DeBakey “Type I”

Points to Consider





?

Prev Card Inter =Yes, Other Card OtherHF = NoCardio Shock =YesAortic Dz = Yes, Symptomatic

Prev Card Inter =Yes, Other Card OtherHF = YessCardio Shock =NoAortic Dz = Yes, Ascending

Prev Card Inter =NoHF = NoCardio Shock =YesAortic Dz = Yes, Dissection

Question 3 Selections:Aortic Valve Etiology = Primary Aortic Disease, Aortic Dissection; Aortic Valve Procedure Performed = Root Replacement w/ Valved Conduit; Aortic Procedure Location = Root, Ascending, and Hemi-Arch.

Aortic Valve Etiology = Primary Aortic Disease, Aortic Dissection; Aortic Valve Procedure Performed = AVR and major root reconstruction with a valved conduit; Aortic Procedure Location = Root and Ascending.

Aortic Valve Etiology = Primary Aortic Disease, Atherosclerotic Aneurysm; Aortic Valve Procedure Performed = AVR and insertion of non-valved conduit in a supra-coronary position; Aortic Procedure Location = Ascending and Hemi-Arch.

Points to Consider

Aortic Valve Etiology

Aortic Valve Procedure

Aortic Procedure Location

Aortic Valve Etiology• Aortic Insufficiency @ Cath found to be “Severe”

• Documented Aortic Dissection

Points to Consider




Primary Aortic Disease, Aortic Dissection

Aortic Valve Procedures

• AVR• Valved conduit

(commercial or custom)• Re-implant coronaries

• AVR • Non-valved graft

in supra-coronary position

• AVR• Root Reconstruction• Valved conduit

Coronaries Intact“Bentall”

Points to Consider





The operation includes AVR, Root + Ascending Aorta Replacement, Re-implantation of Coronary Ostia = Bentall

What portions of the Aorta were involved in this procedure? Where did the Surgeon perform the distal anastomosis?


Points to Consider





What was done? The operation includes AVR, Root +Ascending Aorta Replacement, Re-implantation of Coronary Ostia. = Bentall

What portions of the Aorta were involved in this procedure? Where did the Surgeon perform the distal anastomosis?

Root, Ascending Aorta, Hemi-Arch

Etiology = DissectionProcedure = BentallLocation = Ascending + Hemi Arch

Etiology = DissectionProcedure = AVR+ Root ReconstructLocation = Root +Ascending

Etiology = RuptureProcedure = AVR+ Supra coronary ConduitLocation = Ascending + Hemi Arch

After a prolonged surgery, the patient is transferred to ICU with considerable volume overload and marginal urine output. The surgeon orders UF for hemoconcentration. On the morning of POD #1, the patient is found to be unresponsive, anuric, and has lost pulses in his lower extremities. MRI and CT Scans reveal a CVA, "ischemic" in origin, and a new diagnosis of an abdominal aortic dissection. Urgent TEVAR is undertaken in the Vascular OR to repair the abdominal aorta with limited results. On POD #2, the patient remains unresponsive and anuric with faint pulses in only one limb. UF has been replaced with CRRT due to rising creatinine. Repeat MRI reveals a worsened neurologic condition. On POD #3, the patient's condition is further complicated with worsening lactic acidosis and evidence of ischemic bowel. Given the poor prognosis, the family elects for palliative care measures only. The patient is extubated, and expires on POD #4.

Patient ScenarioPart 2

Question 4 Selections:Re-Op = Yes, Other Cardiac; CVA = Yes, Embolic; Renal failure = Yes, New Dialysis.

Re-Op = Yes, Other Non-Cardiac; CVA = Yes, Undetermined Type; Renal failure = Yes, New Dialysis.

Re-Op = Yes, Other Non-Cardiac; CVA = Yes, Hemorrhagic; Renal failure = Yes, New Dialysis.

Re-Op = Yes, Other Cardiac; CVA = Yes, Undetermined Type; Renal failure = Yes, New Dialysis.

Points to Consider What Re-Operation was performed post-operatively?

What type of stroke did the patient suffer?

Did the patient develop Renal Failure?

New diagnosis of abdominal dissection requires intervention.

TEVAR is undertaken in Vascular Lab.

Cardiac or Non-Cardiac (Vascular) ?

TEVAR




New diagnosis of abdominal (oops) dissection requires intervention.

TEVAR is undertaken in Vascular Lab. Cardiac or Non-Cardiac (Vascular) ?

Embolic, Hemorrhagic, or Undetermined?

Types of CVA

Post-Op CVA








Renal Failure








New requirement for postoperative dialysis Anuria >= 12 hours

ReOp=Yes, Other CardCVA = Yes, EmbolicRF= Yes

ReOp=Yes, Other NonCardCVA = Yes, UnderterminedRF= Yes

ReOp=Yes, Other NonCardCVA = Yes, HemorrhagicRF= Yes

ReOp=Yes, Other CardCVA = Yes, UndeterminedRF= Yes


In-Hospital Post Operative Events include: Operative, Neurologic, Renal.

In-Hospital Post Operative Events include: Pulmonary, Vascular, Other.

All of the above.

Points to Consider Intervention in Vascular Lab = Operative Post Operative Stroke (Undetermined) = Neurologic Ultra Filtration and new Dialysis = Renal

Prolonged Ventilation = Pulmonary Acute Limb Ischemia = Vascular Aortic Dissection, GI Event, MSF(?) = Other


In-Hospital Post Operative Events include: Operative, Neurologic, Renal.

In-Hospital Post Operative Events include: Pulmonary, Vascular, Other.

All of the above.

OperativeNeurologicRenal

PulmonaryVascularOther

All of the Above


The Mortality Cause of Death is: Cardiac

The Mortality Cause of Death is: Neurologic

The Mortality Cause of Death is: Vascular

The Mortality Cause of Death is: Unknown

The Mortality Cause of Death is: Deferred to Surgeon

Points to Consider

What was the Primary cause of death?

What is the “most right” answer?


The Mortality Cause of Death is: Cardiac

The Mortality Cause of Death is: Neurologic

The Mortality Cause of Death is: Vascular

The Mortality Cause of Death is: Unknown

The Mortality Cause of Death is: Deferred to Surgeon Use POCMA as resource, discuss case, or call Jae

Discuss case, ask questions, then call Jae

Per TM, the Primary cause of all PO events Per POCMA, the seminal event that triggered the spiral

Vascular events occurred as a result of initial insult

Occurred as a result of initial surgery. Did not cause the cascade of events that followed

Seriously, please call us!!

Neuro Vascular Cardiac Unknown Surgeon

Documents

Michigan STS Data Managers Meeting - MSTCVSensues, requiring intubation, and pericardiocentesis. Inotropes are started with no improvement in hemodynamics. The patient is immediately