Cardiac sURgery anesthesia Best practices to reduce Acute Kidney Injury (CURB-AKI)

心脏手术麻醉减少急性肾损伤 (CURB-AKI) 的最佳实践

• 批准号: 10656576
• 负责人: Michael Robert Mathis
• 金额: $ 66.4万
• 依托单位: UNIVERSITY OF MICHIGAN AT ANN ARBOR
• 依托单位国家: 美国
• 财政年份: 2022
• 资助国家: 美国
• 起止时间: 2022-07-01 至 2027-05-31
• 项目状态: 未结题
• 来源: https://reporter.nih.gov/project-details/10656576
• 关键词: Acute Renal Failure with Renal Papillary Necrosis; Address; Adoption; Adult; Algorithms; Anesthesia procedures; Anesthesiology; Area Under Curve; Benchmarking; Cardiac; Cardiac Surgery procedures; Cardiopulmonary Bypass; Caring; Characteristics; Chronic Kidney Failure; Clinical; Clinical Trials; Communication; Complication; Data; Data Set; Data Sources; Databases; Dialysis procedure; EHR research; Expenditure; Feedback; Future; Goals; Health Expenditures; Health system; Healthcare; Hemoglobin; Heterogeneity; Hospital Societies; Hospitals; Hypotension; Individual; Infrastructure; Injury to Kidney; Intensive Care Units; Intervention; Intraoperative Care; Kidney; Knowledge; Liquid substance; Measures; Michigan; Multicenter Studies; Natural experiment; Nurses; Operative Surgical Procedures; Outcome; Oxygen; Pathology; Patient risk; Patients; Pattern; Patterns of Care; Performance; Perioperative; Pharmaceutical Preparations; Physiological; Population; Postdoctoral Fellow; Postoperative Care; Postoperative Period; Precision therapeutics; Procedures; Process; Provider; Records; Registries; Reporting; Research; Review Literature; Risk; Risk Adjustment; Risk Factors; Risk Reduction; Societies; Source; Standardization; Techniques; Thoracic Surgeon; Translating; Universities; Update; Validation; Variant; advanced analytics; clinically relevant; cohort; cost; data infrastructure; evidence base; hemodynamics; improved; individualized medicine; innovation; member; modifiable risk; mortality; optimal treatments; personalized approach; personalized care; predictive modeling; standardized care; treatment as usual; treatment effect; treatment strategy

Project Summary Almost 300,000 patients undergo cardiac surgery in the U.S. annually, and up to 30% develop cardiac surgery associated acute kidney injury (CSA-AKI). The complication is potentially preventable and results in 3-4 additional intensive care unit (ICU) days, $10-40K added health expenditures per case, and up to 10-fold increased odds of mortality. In severe cases requiring dialysis, consequences are even greater. While efforts to identify targets for CSA-AKI risk-reducing interventions have focused on underlying patient risk and surgical details, the intraoperative and early ICU periods remain understudied sources of outcome variation. Intraoperative and early ICU periods present unique opportunities for reducing CSA-AKI due to (i) unique renal insults due to altered hemodynamics of cardiopulmonary bypass; (ii) major physiologic shifts and clinical interventions detailed in granular intraoperative and ICU data, and (iii) amenability to process change. A paradigm shift in how CSA-AKI is understood during these periods remains possible through the addition of detailed minute-to-minute intraoperative and early ICU data to factors in traditional prediction models, but requires advanced analytical approaches to identify patterns within the 25,000 physiologic, fluid, medication, and intervention data points available for each patient. The potential value of such patterns is emerging in recent studies, yet remains unvalidated in large, contemporary cardiac surgery populations. Moreover, for CSA-AKI prediction models to be maximally informative, risk-reducing modifiable processes of care are likely not “one size fits all”, as are commonly applied in healthcare despite important heterogeneity of treatment effects across diverse pathologies and procedures. Finally, efforts to translate evidence to practice often fail, due to poor communication of evidence-based, patient-specific benchmarking data to individual clinicians. We propose a multicenter study leveraging the integration of two mature, unique research and quality improvement collaboratives built upon national, standardized registries: the Multicenter Perioperative Outcomes Group (MPOG) and the Society for Thoracic Surgeons (STS) Adult Cardiac Database. MPOG uses nurse- validated, detailed minute-to-minute intraoperative and early ICU data from the EHR for research and quality improvement. Headquartered at University of Michigan and guided by Associate Research Director PI Mathis, MPOG has integrated 16 million patient records across >40 health systems in 22 states and provides monthly automated performance improvement benchmarking reports to 5,000 frontline anesthesiology clinicians. In addition, MPOG has integrated each member hospital’s STS clinical registry to create a unique national “MPOG- STS” dataset of 80,000 cardiac surgeries. We will (i) identify high-impact, modifiable intraoperative and early ICU processes of care associated with reduced CSA-AKI; (ii) estimate the impact of individualized treatment strategies versus standardized or usual care for reducing CSA-AKI and progression to CKD, and (iii) disseminate and assess the effect of precision feedback on CSA-AKI and relevant processes of care.

项目摘要 美国每年有近30万患者接受心脏手术，其中高达30%的患者接受心脏手术 相关急性肾损伤（CSA-AKI）。该并发症可能是可以预防的，并导致3-4例 额外的重症监护室（ICU）天数，每个病例增加10 - 40 K美元的医疗支出， 增加死亡率在需要透析的严重病例中，后果甚至更严重。同时努力 确定CSA-AKI风险降低干预措施的目标，重点是潜在的患者风险和手术风险。 详细来说，术中和早期ICU阶段仍然是未充分研究的结局变化来源。 由于（i）独特的肾脏，术中和早期ICU时期为减少CSA-AKI提供了独特的机会 由于心肺转流的血流动力学改变而导致的损伤;（ii）主要的生理变化和临床 详细的术中和ICU数据中的干预，以及（iii）对过程变化的顺从性。 在这些时期如何理解CSA-AKI的范式转变仍然是可能的， 详细的每分钟术中和早期ICU数据与传统预测模型中的因素， 需要先进的分析方法来识别25，000种生理、液体、药物和 为每位患者提供干预数据点。这种模式的潜在价值正在显现， 研究，但仍未经验证的大型，当代心脏手术人群。此外，对于CSA-AKI 预测模型要最大限度地提供信息，降低风险的可修改的护理过程可能不是“一个尺寸 适合所有人”，这是医疗保健中常用的方法，尽管治疗效果存在重要的异质性。 不同的病理和程序。最后，将证据转化为实践的努力往往会失败，原因是 将基于证据的、患者特定的基准数据传达给临床医生。 我们提出了一项多中心研究，利用两个成熟的，独特的研究和质量整合 建立在国家标准化登记研究基础上的协作改进：多中心围手术期结局 组（MPOG）和胸外科医师协会（STS）成人心脏数据库。MPOG使用护士- 来自EHR的经过验证的、详细的术中和早期ICU数据，用于研究和质量 改进.总部设在密歇根大学，由副研究主任PI马西斯指导， MPOG已经整合了22个州超过40个卫生系统的1600万份患者记录， 向5，000名一线麻醉科临床医生提供自动化绩效改进基准报告。在 此外，MPOG还整合了每个成员医院的STS临床注册表，以创建一个独特的国家“MPOG- STS的80，000例心脏手术数据集。我们将（i）确定高影响力，可修改的术中和早期 与减少CSA-AKI相关的ICU护理过程;（ii）评估个体化治疗的影响 与标准化或常规护理相比，减少CSA-AKI和进展为CKD的策略，以及（iii）传播 并评估精确反馈对CSA-AKI和相关护理过程的影响。