ProTECT IIICST and Transgressions

Tamara Espinoza, MDNov 13, 2012

Targets for Goal Directed Therapy

Pulse Ox ≥ 90% ICP < 20 mmHg Na+ 135 - 145

PaO2 ≥ 100 mmHg PbTO2 ≥ 15 mmHg INR ≤ 1.4

PaCO2 35-45 mmHg CPP > 60 mmHg Plts ≥ 75K/mm3

SBP 100 – 180 mmHg Temp 36 – 38.3°C Hgb ≥ 8 gm/dL

MAP ≥ 80 mmHg pH 7.35 – 7.45 Gluc 80-180 mg/dL

* With Hypertonic Saline Therapy: Na 145 – 160 mmol/L

Transgression Hours

 # Total Transgression Hours # Unacceptable Transgression Hours # Transgression Hours Not Yet

Coded% Unacceptable Transgression

Hours

All 78252 6075 1365 7.90%

Mean Arterial Pressure Transgressions 35204 878 68 2.50%

Temperature Transgressions 12631 2208 347 17.97%

Systolic Blood Pressure Transgressions 7539 1123 168 15.24%

Intracranial Pressure Transgressions 6973 98 8 1.41%

CPP Transgressions 4257 87 0 2.04%

Glucose Transgressions 3836 551 226 15.26%

PaCO2 Transgressions 2973 663 353 25.31%

PaO2 Transgressions 2229 8 8 0.36%

Hemoglobin Transgressions 822 198 115 28.01%

Oxygen Saturation Transgressions 741 66 22 9.18%

Brain Tissue Oxygen Transgressions 541 22 0 4.07%

INR Transgressions 406 136 49 38.10%

Platelet Transgressions 100 37 1 37.37%

CST Keys to Success

Have a Neurosurgery, Trauma Surgery, and Neurointensivist Champion

Make friends! Have cell phone and pager numbers

Face time on the unitsMeet monthly with team when

patients in house

NEUROSURGEONS

TRAUMA SURGEONS

NEUROINTENSIVIST

ED DOCSEMS

NURSING

ANESTHESIA REHAB

Research Experience

Team approach

Clinical expertise onsite

Absol

ute c

omm

itmen

t to s

ucce

ss

CST Keys to Success

Include Nursing ADMIN in meetings

Consider Nurse Champion on Units

Bring FOOD!

Face time on the units

Consider Trauma rounds

PI’s – DON’T leave your coordinators alone to do it!

PI’s

BACK UP YOUR COORDINATORS!!!!!!

DO NOT LEAVE THEM HANGING

Refer recalcitrant cases to the Emory Transgression Team (Bethany, David, or myself)

Transgressions Hints

Spontaneous recovery should only be marked if the transgression returned to normal by the following hour.

Do NOT mark “other” and say that no

intervention was done or to repeat an intervention that has already been marked.

Interventions should be marked for the hour they were done.If they were not done in the same hour as the transgression please put a note in general comments. *It is actually possible to put the intervention in on another hour but you have to dismiss a warning.

Transgressions Hints

If a transgression occurs near closing of one day, and the treatment occurs on the following day, place a note in the comments section

The reverse is also true “Intubation” should be checked for every hour

a PaO2 transgression occurs. Craniectomy is only documented the hour of

the surgery (although it should be noted in the comments daily while the flap is removed)

O2 sat and PaO2 transgression

If the subject is intubated it should be checked anytime there is a transgression

Supplemental O2 was meant for non-intubated patients (example NC or facemask)

PCO2 transgressions

Not often treated

Should not be prophylactically driving CO2 down

May drive CO2 down to 30-35 for ICP managment.

Glucose transgression

If subject on insulin drip and the rate is changed, mark “other” and specify that the rate was ↑↓

Temperature transgression

If Hypothermia is being used for intractable ICP please put a note in the general comment section

Normothermia should be maintained even in the OR

Systolic BP/MAP Transgressions

Even if the subject is only on maintenance fluid mark IVF.

If the patient has an IV rate increase or receives a bolus then mark “other” and specify

If subject is on inotrop/pressors and rate is being tritrated also mark “other” and specify if rate was ↑↓

Intracranial Pressure Transgressions

Should not stay in a Tier longer than 120 minutes if ICP not responding to treatment

If ICP <20 after intervention and then elevates >20, start back at Tier 1

Remember HTS should be in boluses for ICP management

Hypothermia only allowed as “rescue therapy” once all 3 Tiers have failed

CPP Transgressions

Remember if the art line is zeroed at the level of the atrium instead of the tragus and the CPPs are running in the 55-59 range then it is really lower and should be aggressively managed

CPP = MAP - ICP

Hemoglobin Transgressions

If risk outweighs benefit (particularly after acute phase) then note in general comment section

Transgression Examples

Case 1

Day 2 after his index injury, patient WC develops HTN with SBP range from 162 – 205 (5 intermittent hours above SBP 180)

PMHx = HTN*, DM*Study team notes that the patient’s baseline (pre-injury) blood pressure ranged 160s-200s/80-90s

Current meds = ISS, Morphine PRN, Dilantin, maintenance IVF

No additional meds given on Day 2

Case 1

For the 5 hours of SBP transgressions, which of the following should be checked:

a. Spontaneous Resolution - the SBP wax/wane throughout the day and resolved without treatment

b. Nothing – the transgression was not intervened on

c. IVF – the patient is receiving maintenance IVF

d. Nothing – this is not a transgression as the patient is at his baseline BP

e. Other – the patient is receiving Morphine which is known to lower blood pressure

Case 2

45 yo M s/p MVC with randomization GCS of 8. Intubated in the ED for airway protection and expectant course. On day 3, the subject has the following ABG and vent settings7.31 / 52 / 102 / 23 / -2

AC, Vt 500, Rate 12, Peep 5, FiO2 55%

Transgression ExamplesCase 2

To improve the subjects PaCO2, the treating team may:

a. Increase the FiO2

b. Decrease the PEEP

c. Increase the respiratory rate

d. Lower the tidal volume

e. Do Nothing – the patient is over breathing the vent

Transgression ExamplesCase 2

How would this be documented on the CRF?

a. Other – rate change

b. Other – intubation

c. Minute ventilation change

d. Supplemental oxygen

e. a and b

f. c and d

Transgression ExamplesCase 3

Patient AB has the following pulse Ox readings:

(8:00) 86%(13:00) 94%(17:00) 99%(22:00) 96%

TRUE OR FALSE – For the transgression at 8am, “spontaneous resolution” should be checked on the CRF. FALSE

Case 4

It is day 6 for patient ML in the ICU. She is intubated, sedated, and on an insulin gtt for her difficult to control DM and maintenance IVF. Her latest glucose readings are:

(10:00) 305(11:00) 315(12:00) 319

At 12:23 pm, the treating team gives her a bolus of insulin and increases her drip rate

Case 4

How should the CRF be completed for the transgressions at 12pm?

a. Insulin gtt

b. Left blank – no interventions were done at this time

c. Other – insulin drip rate change

d. Other - IVF

e. Insulin bolus

Case 4

How should the CRF be completed for the transgressions at 10am and 11am?

a. Insulin gtt

b. Left blank – no interventions were done at this time

c. Other – insulin gtt and rate

d. Other - IVF

e. Insulin bolus

Final Thoughts….

Judicious use of the “other” column Only interventions that directly impact the

transgression

Comments are extremely helpful

Redundancy is much appreciated Temperature and blood pressure are a

common problem – stay on your treating

providers

Final Thoughts….

Spontaneous recovery is only accepted if

recovery occurred within one hour (and

you have documentation to prove it) IVF for HYPOtension (even if only

maintenance fluids) IVF are not a treatment for HYPERtension

Final Thoughts….

Call/Email with

questions

THANK YOU