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