Post on 28-Dec-2015
The approach to adopting new equipment, drugs and techniques into practice
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
fresh gas4/4
Ayre P. Anesth Analg (1937) 16: 331
Endotracheal anaesthesia for babies with special reference to hare-lip and cleft palate operations
Airway management and ventilationAirway management and ventilation
ECG and NIBP plus careful clinical evaluation
MonitoringMonitoring
Eur J Anaesthesiol (2011) 28: 637-639
Hypotonic solutions: glucose 5% with sodium 30 mmol/l
Fluid therapyFluid therapy
Postoperative carePostoperative care
There is a continuous change over the time
1974 2012
• 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
• Desflurane
• Propofol
• Remifentanil
• Atracurium
• Rocuronium
• Sugammadex
• Ropivacaine
There is a continuous change over the time
agitated children
laryngospasm
hypotension, PRIS
insufficient pain relief
• General remarks
• Drugs and equipment
• New concepts
• Conclusions
• available • affordable
The introduction of ultrasoundThe 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®(1994) 2000 Site Rite®
2006 Sono Site 2006 Sono Site2006 modern equipment becomes widely available
2006 modern equipment becomes widely available
2006 Sono Site 2006 Sono Site2006 modern equipment becomes widely available
2006 modern equipment becomes widely available
… we enthusiastically learned it by trial and error …
2013 an established technique2013 an established technique
Many courses and workshops
Procedures well defined
Institutionalized teaching
Young people => success
Luyet C et al. Anesthesiology Research and Practice (2010) 309462
USNS
Brachial plexus block
With and without ultrasound
2002 NICE recommended ultrasound2002 NICE recommended ultrasound
"It's nice to see in the dark"
Scott DHT Br J Anaesth (2003) 90: 269-272
Available technology is not usedAvailable technology is not used
Grebenik CR et al. (Oxford) Br J Anaesth (2004) 92: 827-830
"NICE guidelines for CVC in children Is the evidence base sufficient?"
"NICE guidelines for CVC in children Is the evidence base sufficient?"
0
20
40
60
80
100
success carotid puncture
ultrasoundlandmark
• Consultant paediatric anaesthetists• landmark (n = 65) ultrasound (n = 59)• Neonates to 8 y; 2.0 kg - 24.6 kg
Meta-analysisSigaut S et al.
Paediatr Anaesth(2009) 19: 1199-206
Evidence-based medicineEvidence-based medicine
Hind D et al. BMJ (2003) 327: 361-368
0 0.2 0.4 0.6 0.8 1 1.2 1.4
childrenadults
complications
> 1 attempt
failure
relative risk
• meta-analysis• data up to 2001• internal jugular
18 papers1646 patients
1000
20
40
60
80
100
20minutes
ultrasound
% in
sert
ed c
ath
eter
s
Hosokawa K et al. Anesthesiology (2007) 107: 720-724
Visual approachVisual approach
60 neonates and infants < 7.5 kg• US => landmarks• US real-time
ET
Jöhr M et al. Paediatr Anaesth (2010) 20: 105
5 months, 6.5 kg
ET
Jöhr M et al. Paediatr Anaesth (2010) 20: 105
5 months, 6.5 kg
Abrahams MS et al. Br J Anaesth (2010) 102: 408-17
Meta-analysis
• 13 papers• 946 patients
0.41
0.16
0 0.5 1 1.5
vascularpuncture
failure
RR
• faster• longer
With ultrasound => less failures Evidence-based Medicine
With ultrasound => less failures Evidence-based Medicine
EBM – “lost in translation”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
?
cricoid pressure
Available technology is not usedAvailable technology is not used
ventilator
teacher
trainee
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
7 weeks old boy 5.6 kg
Videolaryngoscopy
• guide and control• reach success
Schüpfer G, Jöhr M. Paediatr Anaesth (2005) 15: 461-469
C
W
Institutional learning curveInstitutional learning curve
Institutional learning curveInstitutional learning curve
Schüpfer G, Jöhr M. Paediatr Anaesth (2005) 15: 465-469
number of patients
succ
ess
rate
Psoas compartment block100 patients5.9 -106 kg
Success• first attempt• no complication• analgesia
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
Pfenninger J. Paediatr Anaesth (1992) 2: 85-87
within 8 years: 8 severe cases => 3 deaths
Hyponatremia is a lethal threatHyponatremia is a lethal threat
Arieff AI et al. BMJ (1992) 304: 1218-1222
24'412 children, within 3 years: 83 cases => 9 deaths
Moritz ML, Ayus JC. Pediatrics (2003) 111: 227-230
• > 50 cases, 26 deaths• more than half of the cases in healthy children after minor surgery
"…Isotonic saline seems to be the preferred fluid for administration to hospitalized patients,
as they are at high risk for developing hyponatremia …"
Hyponatremia is a lethal threatHyponatremia is a lethal threat
• NaCl 0.9%• measuring Na
Duke T, Molyneux EM. Lancet (2003) 362: 1320-1323Intravenous fluids for seriously ill children: time to reconsider
Hyponatremia is common (20-45%)
• meningitis• encephalitis• sepsis• pneumonia• bronchiolitis
NaCl 0.9%(+ glucose)
Hyponatremia is a lethal threatHyponatremia is a lethal threat
Eur J Anaesthesiol (2011) 28: 637-639
Fluid therapyFluid therapy
Dubois MC et al. Paediatr Anaesth (1992) 2: 99-104
Sümpelmann R et al. Paediatr Anaesth (2010) 20: 977-81
Niesters M et al. Leiden Br J Anaesth (2013) 110 Feb: 175-182
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
Dosing errors prescription – administration
Dosing errors prescription – administration
Doherty C et al. Pediatrics (2012) 129: 916-924
Tenfold medication errors: 5 years’ experience at a university-affiliated paediatric hospital
Tenfold medication errors: 5 years’ experience at a university-affiliated paediatric hospital
252 cases within 5 years
once a week
252 cases within 5 years
once a week
Dosing errors prescription – administration
Dosing errors prescription – administration
Jani YH et al. Qual Saf Health Care (2010) 19: 337-340 Jani YH et al. Qual Saf Health Care (2010) 19: 337-340
2.2
1.2
0 1 2 3 %%
Paediatric dosing errors before and after
electronic prescribing
Paediatric dosing errors before and after
electronic prescribing
beforebefore
afterafter
The school of pharmacyUniversity of London
The school of pharmacyUniversity of London
Dosing errors prescription – administration
Dosing errors prescription – administration
On the ward and on the PICU Electronic prescriptions
On the ward and on the PICU Electronic prescriptions
prescriptionprescription
cross check and administrationcross check and administration
physicianphysician
patientpatient
thomas.berger@luks.chthomas.berger@luks.ch
Ventilation by mask can cause problems
CAVE: gastric distensionCAVE: gastric distension
Respiratory insufficiency
CAVE: gastric distensionCAVE: gastric distension
Since 2002 with the anaesthesia ventilator
Ventilator derived mask ventilation before endotracheal intubation
Ventilator derived mask ventilation before endotracheal intubation
PCV (pressure controlled ventilation)
PIP 13 cm H2OPEEP 3 cm H2ORate 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
Facemask pressure-controlled ventilation in children:What is the pressure limit?
Lagarde S et al. Anesth Analg (2010) 110: 1676-1679
100 children, 1-16 yPIP increasing 10-15-20-25 cm H2O
• small children more prone to gastric distension• < 15 cm H2O problems rarely occurred
With the anaesthesia ventilator => a new strategy
• General remarks
• Drugs and Equipment
• New concepts
• 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.
ConclusionsConclusions
Visual approachVisual approach
Hosokawa K et al. Anesthesiology (2007) 107: 720-724
60 neonates and infants < 7.5 kg• US => landmarks• US real-time
0 20 40 60 80 100
< 3 attempts
one puncture
complications
Kyoto