The approach to adopting new equipment,
drugs and techniques into practice
Martin Jöhr
Paediatric Anaesthesia
Department of Anaesthesia
Kantonsspital
6000 Luzern 16, Switzerland
martin.joehr@luks.ch
Airway management and ventilation
fresh gas
4/4
Ayre P. Anesth Analg (1937) 16: 331
Endotracheal anaesthesia for babies
with special reference to hare-lip and cleft palate operations
Monitoring
ECG and NIBP plus careful clinical evaluation
Fluid therapy
Hypotonic solutions: glucose 5% with sodium 30 mmol/l
Eur J Anaesthesiol (2011) 28: 637-639
Postoperative care
1974
2012
There is a continuous change over the time
• Ether
• Halothane
• Enflurane
• Alcuronium
• Succinylcholine
• Pethidine
• Morphine
• Tetracaine
There is a continuous change over the time
• Sevoflurane
• Desflurane
• Propofol
• Remifentanil
• Atracurium
• Rocuronium
• Sugammadex
• Ropivacaine
There is a continuous change over the time
• Sevoflurane
agitated children
• Desflurane
laryngospasm
• Propofol
hypotension, PRIS
• Remifentanil
insufficient pain relief
• Atracurium
• Rocuronium
• Sugammadex
• Ropivacaine
There is a continuous change over the time
• General remarks
• Drugs and equipment
• New concepts
• Conclusions
• available
• affordable
The introduction of ultrasound
1. Theory
• theoretical knowledge (lectures)
• knowledge of published experience
2. Training (simulators)
• phantoms
• cadavers
3. Practice (patients)
• supervised
• guided
1. Theory
• theoretical knowledge (lectures)
• knowledge of published experience
2. Training (simulators)
• phantoms
• cadavers
3. Practice (patients)
• supervised
• guided
(1994) 2000 Site
®
Rite
2006 modern
equipment
2006
Sono Site becomes
widely available
2006 modern
equipment
2006
Sono Site becomes
widely available
… we enthusiastically learned it by trial and error …
2013 an established technique
Many courses and workshops
Procedures well defined
Institutionalized teaching
Young people => success
US
NS
Brachial plexus block
With and without ultrasound
Luyet C et al. Anesthesiology Research and Practice (2010) 309462
Available technology is not used
2002 NICE recommended ultrasound
"It's nice to see in the dark"
Scott DHT Br J Anaesth (2003) 90: 269-272
"NICE guidelines for CVC in children
Is the evidence base sufficient?"
100
• Consultant paediatric anaesthetists
• landmark
(n = 65)
ultrasound
(n = 59)
• Neonates to 8 y; 2.0 kg - 24.6 kg
80
60
40
ultrasound
landmark
20
0
success
carotid puncture
Meta-analysis
Sigaut S et al.
Paediatr Anaesth
(2009) 19: 1199-206
Grebenik CR et al. (Oxford) Br J Anaesth (2004) 92: 827-830
Evidence-based medicine
• meta-analysis
• data up to 2001
• internal jugular
18 papers
1646 patients
complications
> 1 attempt
children
adults
failure
0 0.2 0.4 0.6 0.8 1 1.2 1.4
relative risk
Hind D et al. BMJ (2003) 327: 361-368
% inserted catheters
Visual approach
100
ultrasound
60 neonates and
infants < 7.5 kg
• US => landmarks
• US real-time
80
60
40
20
0
0
10
minutes
20
Hosokawa K et al. Anesthesiology (2007) 107: 720-724
ET
5 months, 6.5 kg
Jöhr M et al. Paediatr Anaesth (2010) 20: 105
ET
5 months, 6.5 kg
Jöhr M et al. Paediatr Anaesth (2010) 20: 105
With ultrasound => less failures
Evidence-based Medicine
vascular
puncture
failure
RR 0
Meta-analysis
• 13 papers
• 946 patients
0.16
• faster
• longer
0.41
0.5
1
1.5
Abrahams MS et al. Br J Anaesth (2010) 102: 408-17
EBM – “lost in translation”
• missing equipment
• high cost
• missing appreciation
Lenfant C: Clinical research to clinical practice – lost in translation?
NEJM (2003) 349: 868-874
Available technology is not used
cricoid pressure
ventilator
trainee
teacher
Videolaryngoscopy
• guide and control
• reach success
7 weeks old boy
5.6 kg
Videolaryngoscopy
• guide and control
• reach success
7 weeks old boy
5.6 kg
Videolaryngoscopy
• guide and control
• reach success
7 weeks old boy
5.6 kg
Institutional learning curve
W
C
Schüpfer G, Jöhr M. Paediatr Anaesth (2005) 15: 461-469
Institutional learning curve
Psoas compartment block
success rate
100 patients
5.9 -106 kg
Success
• first attempt
• no complication
• analgesia
number of patients
Schüpfer G, Jöhr M. Paediatr Anaesth (2005) 15: 465-469
1. Learn (lectures)
2. Train (simulators)
3. Practice (peer)
• General remarks
• Drugs and Equipment
• New concepts
• Conclusions
• “new in the focus”
• “contagious ideas”
Trauma, surgery, illness
=> ADH↑ => water is retained
Hyponatremia is a lethal threat
Pfenninger J. Paediatr Anaesth (1992) 2: 85-87
within 8 years: 8 severe cases => 3 deaths
Arieff AI et al. BMJ (1992) 304: 1218-1222
24'412 children, within 3 years: 83 cases => 9 deaths
Hyponatremia is a lethal threat
• > 50 cases, 26 deaths
• more than half of the cases in
healthy children after minor surgery
• NaCl 0.9%
• measuring Na
"…Isotonic saline seems to be the preferred fluid for administration
to hospitalized patients,
as they are at high risk for developing hyponatremia …"
Moritz ML, Ayus JC. Pediatrics (2003) 111: 227-230
Hyponatremia is a lethal threat
Hyponatremia is common (20-45%)
• meningitis
• encephalitis
• sepsis
• pneumonia
• bronchiolitis
NaCl 0.9%
(+ glucose)
Duke T, Molyneux EM. Lancet (2003) 362: 1320-1323
Intravenous fluids for seriously ill children: time to reconsider
Fluid therapy
Eur J Anaesthesiol (2011) 28: 637-639
Dubois MC et al. Paediatr Anaesth (1992) 2: 99-104
Sümpelmann R et al. Paediatr Anaesth (2010) 20: 977-81
Dosing errors
prescription – administration
Case reports on opioid induced complications
27 patients, 24 papers => 7 deaths
- renal failure + morphine
- CYP2D6 + codeine
- OSAS + opioids
8 x iatrogenic
6 x error by 10
Niesters M et al. Leiden Br J Anaesth (2013) 110 Feb: 175-182
Dosing errors
prescription – administration
Tenfold medication errors: 5 years’ experience at a
university-affiliated paediatric hospital
252 cases
within 5 years
once a week
Doherty C et al. Pediatrics (2012) 129: 916-924
Dosing errors
prescription – administration
Paediatric dosing errors
before and after
electronic prescribing
1.2
after
2.2
before
0
1
2
The school of pharmacy
University of London
3%
Jani YH et al. Qual Saf Health Care (2010) 19: 337-340
On the ward and on the PICU
Electronic prescriptions
physician
prescription
cross check and administration
patient
thomas.berger@luks.ch
Ventilation by mask can cause problems
CAVE: gastric distension
CAVE: gastric distension
Respiratory insufficiency
Since 2002 with the anaesthesia ventilator
Ventilator derived mask ventilation before
endotracheal intubation
PCV (pressure controlled ventilation)
PIP
PEEP
Rate
13 cm H2O
3 cm H2O
age dependent
Von Goedecke A et al.
Anesth Analg
(2004) 98: 260-263
Ventilator derived mask ventilation …
Tracy MB et al. Arch Dis Child Fetal Neonatal Ed
(2011) 296: F201-5
The "educated hand". Can anesthesiologists assess changes in
neonatal pulmonary compliance manually?
Spears RS Jr et al. Anesthesiology (1991) 75: 693-6
100 children, 1-16 y
PIP increasing 10-15-20-25 cm H2O
• small children more prone to gastric distension
• < 15 cm H2O problems rarely occurred
Facemask pressure-controlled ventilation in children:
What is the pressure limit?
Lagarde S et al. Anesth Analg (2010) 110: 1676-1679
With the anaesthesia ventilator => a new strategy
• General remarks
• Drugs and Equipment
• New concepts
• Conclusions
Conclusions
• The clinical practice of paediatric anaesthesia is
continuously changing in an institution.
• The success of this process - change in a good direction - is
heavily dependent on the presence of practitioners who
are well aware of the published literature, who go to
conferences and are connected with the paediatric
anaesthetic community.
• They have the duty to select good concepts, evaluate them
in clinical practice, teach them to other members of the
department and then to re-evaluate if really a benefit
results.
Visual approach
60 neonates and
infants < 7.5 kg
• US => landmarks
• US real-time
complications
one puncture
< 3 attempts
Kyoto
0
20
40
60
80
100
Hosokawa K et al. Anesthesiology (2007) 107: 720-724