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

2. Targets for Goal Directed Therapy Pulse Ox ≥ 90%ICP < 20 mmHgNa + 135 - 145 PaO2 ≥ 100 mmHgPbTO2 ≥ 15 mmHgINR ≤ 1.4 PaCO2 35-45 mmHgCPP > 60 mmHgPlts ≥ 75K/mm 3 SBP 100 – 180 mmHgTemp 36 – 38.3°CHgb ≥ 8 gm/dL MAP ≥ 80 mmHgpH 7.35 – 7.45Gluc 80-180 mg/dL * With Hypertonic Saline Therapy: Na 145 – 160 mmol/L

3. # Total Transgression Hours# Unacceptable Transgression Hours # Transgression Hours Not Yet Coded % Unacceptable Transgression Hours All 78252607513657.90% Mean Arterial Pressure Transgressions 35204878682.50% Temperature Transgressions 12631220834717.97% Systolic Blood Pressure Transgressions 7539112316815.24% Intracranial Pressure Transgressions 69739881.41% CPP Transgressions 42578702.04% Glucose Transgressions 383655122615.26% PaCO2 Transgressions 297366335325.31% PaO2 Transgressions 2229880.36% Hemoglobin Transgressions 82219811528.01% Oxygen Saturation Transgressions 74166229.18% Brain Tissue Oxygen Transgressions 5412204.07% INR Transgressions 4061364938.10% Platelet Transgressions 10037137.37%

4.  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. Research Experience Team approach Clinical expertise onsite Absolute commitment to success

6.  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.  BACK UP YOUR COORDINATORS!!!!!!  DO NOT LEAVE THEM HANGING  Refer recalcitrant cases to the Emory Transgression Team (Bethany, David, or myself)

9.  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.

10.  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.  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.  Not often treated  Should not be prophylactically driving CO2 down  May drive CO2 down to 30-35 for ICP managment.

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

14.  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.  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.  Should not stay in a Tier longer than 120 minutes if ICP not responding to treatment  If ICP 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.  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.  If risk outweighs benefit (particularly after acute phase) then note in general comment section

20. 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. 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. 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. 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. 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.  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.  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.  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.  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.  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.  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. Call/Email with questions THANK YOU