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ProTECT III

CST and Transgressions. ProTECT III. Tamara Espinoza, MD Nov 13, 2012. Targets for Goal Directed Therapy . * With Hypertonic Saline Therapy: Na 145 – 160 mmol /L . Transgression Hours. CST Keys to Success. Have a Neurosurgery, Trauma Surgery, and Neurointensivist Champion

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ProTECT III

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  1. CST and Transgressions ProTECT III Tamara Espinoza, MD Nov 13, 2012

  2. Targets for Goal Directed Therapy * With Hypertonic Saline Therapy: Na 145 – 160 mmol/L

  3. Transgression Hours

  4. CST Keys to Success • Have a Neurosurgery, Trauma Surgery, and Neurointensivist Champion • Make friends! Have cell phone and pager numbers • Face time on the units • Meet monthly with team when patients in house

  5. Clinical expertise onsite Research Experience TRAUMA SURGEONS EMS NEUROSURGEONS ED DOCS Rehab Anesthesia NEUROINTENSIVIST Absolute commitment to success Team approach Nursing

  6. CST Keys to Success • Include Nursing ADMIN in meetings • Consider Nurse Champion on Units • Bring FOOD! • Face time on the units • Consider Trauma rounds

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

  8. PI’s • BACK UP YOUR COORDINATORS!!!!!! • DO NOT LEAVE THEM HANGING • Refer recalcitrant cases to the Emory Transgression Team (Bethany, David, or myself)

  9. 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.Ifthey 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.

  10. 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)

  11. 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)

  12. PCO2 transgressions • Not often treated • Should not be prophylactically driving CO2 down • May drive CO2 down to 30-35 for ICP managment.

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

  14. 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

  15. 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 ↑↓

  16. 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

  17. 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

  18. Hemoglobin Transgressions • If risk outweighs benefit (particularly after acute phase) then note in general comment section

  19. Transgression Examples

  20. 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

  21. 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

  22. 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 settings 7.31 / 52 / 102 / 23 / -2 AC, Vt 500, Rate 12, Peep 5, FiO2 55%

  23. 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

  24. 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

  25. 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

  26. 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

  27. 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

  28. 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

  29. 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

  30. 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

  31. Final Thoughts…. THANK YOU Call/Email with questions

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