Post on 14-Dec-2015
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