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

项目摘要 在美国，每年有近30万名患者接受心脏手术，高达30%的患者接受心脏手术 合并急性肾损伤(CsA-AKI)。并发症是潜在的可以预防的，结果是3-4 额外的重症监护病房(ICU)天数，每个病例增加10-4万美元的医疗支出，最高可增加10倍 死亡几率增加。在需要透析的严重病例中，后果甚至更大。在努力争取 确定CSA-AKI降低风险干预的目标，重点放在潜在的患者风险和手术上 详细地说，术中和ICU早期仍未被充分研究结果差异的来源。 由于(I)独特的肾脏，术中和ICU早期为减少CsA-AKI提供了独特的机会 体外循环血流动力学改变所致的损伤；(Ii)主要生理变化和临床 细粒的术中和ICU数据中详述的干预措施，以及(Iii)处理变化的适应性。 在这些时期对CSA-AKI的理解仍有可能通过添加 详细的术中和早期ICU数据与传统预测模型中的因素有关，但 需要先进的分析方法来识别25,000种生理、液体、药物和 为每个患者提供干预数据点。近年来，这种模式的潜在价值正在显现。 研究，但仍未在大规模的当代心脏外科人群中得到验证。此外，对于CSA-AKI 具有最大信息量、可降低风险、可修改的护理流程的预测模型可能不是“一成不变的” 尽管治疗效果存在重要的异质性，但在医疗保健中普遍应用 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，原因是糟糕 向个别临床医生传达基于证据的、特定于患者的基准数据。 我们提出了一项多中心研究，利用两项成熟、独特的研究和质量的整合 建立在国家标准化登记基础上的改善协作：多中心围手术期结果 集团(MPOG)和胸部外科医生学会(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 进步。总部设在密歇根大学，由副研究主任皮马西斯指导， MPOG已经整合了22个州的40个医疗系统中的1600万份患者记录，并每月提供 自动化绩效改进基准报告给5,000名一线麻醉学临床医生。在……里面 此外，MPOG还整合了各成员医院的STS临床注册，创建了独特的全国“MPOG- STS“包含80,000例心脏手术的数据集。我们将(I)确定高影响、可修改的术中和早期 与CsA-AKI减少相关的ICU护理流程；(Ii)评估个体化治疗的影响 减少CSA-AKI和进展为CKD的策略与标准化或常规护理相比，以及(Iii)传播 评估精确反馈对CSA-AKI及相关护理过程的影响。

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.