Types of Anaesthesia LOCAL ANAESTHESIA AND REGIONAL ANAESTHESIA PRPD/DN/2011.
The approach to adopting new equipment, drugs and techniques into practice Martin Jöhr Paediatric...
-
Upload
barnard-hardy -
Category
Documents
-
view
216 -
download
2
Transcript of The approach to adopting new equipment, drugs and techniques into practice Martin Jöhr Paediatric...
![Page 1: The approach to adopting new equipment, drugs and techniques into practice Martin Jöhr Paediatric Anaesthesia Department of Anaesthesia Kantonsspital.](https://reader035.fdocuments.in/reader035/viewer/2022062717/56649e4c5503460f94b419b6/html5/thumbnails/1.jpg)
![Page 2: The approach to adopting new equipment, drugs and techniques into practice Martin Jöhr Paediatric Anaesthesia Department of Anaesthesia Kantonsspital.](https://reader035.fdocuments.in/reader035/viewer/2022062717/56649e4c5503460f94b419b6/html5/thumbnails/2.jpg)
![Page 3: The approach to adopting new equipment, drugs and techniques into practice Martin Jöhr Paediatric Anaesthesia Department of Anaesthesia Kantonsspital.](https://reader035.fdocuments.in/reader035/viewer/2022062717/56649e4c5503460f94b419b6/html5/thumbnails/3.jpg)
![Page 4: The approach to adopting new equipment, drugs and techniques into practice Martin Jöhr Paediatric Anaesthesia Department of Anaesthesia Kantonsspital.](https://reader035.fdocuments.in/reader035/viewer/2022062717/56649e4c5503460f94b419b6/html5/thumbnails/4.jpg)
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
![Page 5: The approach to adopting new equipment, drugs and techniques into practice Martin Jöhr Paediatric Anaesthesia Department of Anaesthesia Kantonsspital.](https://reader035.fdocuments.in/reader035/viewer/2022062717/56649e4c5503460f94b419b6/html5/thumbnails/5.jpg)
![Page 6: The approach to adopting new equipment, drugs and techniques into practice Martin Jöhr Paediatric Anaesthesia Department of Anaesthesia Kantonsspital.](https://reader035.fdocuments.in/reader035/viewer/2022062717/56649e4c5503460f94b419b6/html5/thumbnails/6.jpg)
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
![Page 7: The approach to adopting new equipment, drugs and techniques into practice Martin Jöhr Paediatric Anaesthesia Department of Anaesthesia Kantonsspital.](https://reader035.fdocuments.in/reader035/viewer/2022062717/56649e4c5503460f94b419b6/html5/thumbnails/7.jpg)
ECG and NIBP plus careful clinical evaluation
MonitoringMonitoring
![Page 8: The approach to adopting new equipment, drugs and techniques into practice Martin Jöhr Paediatric Anaesthesia Department of Anaesthesia Kantonsspital.](https://reader035.fdocuments.in/reader035/viewer/2022062717/56649e4c5503460f94b419b6/html5/thumbnails/8.jpg)
Eur J Anaesthesiol (2011) 28: 637-639
Hypotonic solutions: glucose 5% with sodium 30 mmol/l
Fluid therapyFluid therapy
![Page 9: The approach to adopting new equipment, drugs and techniques into practice Martin Jöhr Paediatric Anaesthesia Department of Anaesthesia Kantonsspital.](https://reader035.fdocuments.in/reader035/viewer/2022062717/56649e4c5503460f94b419b6/html5/thumbnails/9.jpg)
Postoperative carePostoperative care
![Page 10: The approach to adopting new equipment, drugs and techniques into practice Martin Jöhr Paediatric Anaesthesia Department of Anaesthesia Kantonsspital.](https://reader035.fdocuments.in/reader035/viewer/2022062717/56649e4c5503460f94b419b6/html5/thumbnails/10.jpg)
There is a continuous change over the time
1974 2012
![Page 11: The approach to adopting new equipment, drugs and techniques into practice Martin Jöhr Paediatric Anaesthesia Department of Anaesthesia Kantonsspital.](https://reader035.fdocuments.in/reader035/viewer/2022062717/56649e4c5503460f94b419b6/html5/thumbnails/11.jpg)
• Ether
• Halothane
• Enflurane
• Alcuronium
• Succinylcholine
• Pethidine
• Morphine
• Tetracaine
There is a continuous change over the time
![Page 12: The approach to adopting new equipment, drugs and techniques into practice Martin Jöhr Paediatric Anaesthesia Department of Anaesthesia Kantonsspital.](https://reader035.fdocuments.in/reader035/viewer/2022062717/56649e4c5503460f94b419b6/html5/thumbnails/12.jpg)
• Sevoflurane
• Desflurane
• Propofol
• Remifentanil
• Atracurium
• Rocuronium
• Sugammadex
• Ropivacaine
There is a continuous change over the time
![Page 13: The approach to adopting new equipment, drugs and techniques into practice Martin Jöhr Paediatric Anaesthesia Department of Anaesthesia Kantonsspital.](https://reader035.fdocuments.in/reader035/viewer/2022062717/56649e4c5503460f94b419b6/html5/thumbnails/13.jpg)
• Sevoflurane
• Desflurane
• Propofol
• Remifentanil
• Atracurium
• Rocuronium
• Sugammadex
• Ropivacaine
There is a continuous change over the time
agitated children
laryngospasm
hypotension, PRIS
insufficient pain relief
![Page 14: The approach to adopting new equipment, drugs and techniques into practice Martin Jöhr Paediatric Anaesthesia Department of Anaesthesia Kantonsspital.](https://reader035.fdocuments.in/reader035/viewer/2022062717/56649e4c5503460f94b419b6/html5/thumbnails/14.jpg)
• General remarks
• Drugs and equipment
• New concepts
• Conclusions
• available • affordable
![Page 15: The approach to adopting new equipment, drugs and techniques into practice Martin Jöhr Paediatric Anaesthesia Department of Anaesthesia Kantonsspital.](https://reader035.fdocuments.in/reader035/viewer/2022062717/56649e4c5503460f94b419b6/html5/thumbnails/15.jpg)
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
![Page 16: The approach to adopting new equipment, drugs and techniques into practice Martin Jöhr Paediatric Anaesthesia Department of Anaesthesia Kantonsspital.](https://reader035.fdocuments.in/reader035/viewer/2022062717/56649e4c5503460f94b419b6/html5/thumbnails/16.jpg)
1. Theory• theoretical knowledge (lectures)• knowledge of published experience
2. Training (simulators)• phantoms• cadavers
3. Practice (patients)• supervised• guided
![Page 17: The approach to adopting new equipment, drugs and techniques into practice Martin Jöhr Paediatric Anaesthesia Department of Anaesthesia Kantonsspital.](https://reader035.fdocuments.in/reader035/viewer/2022062717/56649e4c5503460f94b419b6/html5/thumbnails/17.jpg)
(1994) 2000 Site Rite®(1994) 2000 Site Rite®
![Page 18: The approach to adopting new equipment, drugs and techniques into practice Martin Jöhr Paediatric Anaesthesia Department of Anaesthesia Kantonsspital.](https://reader035.fdocuments.in/reader035/viewer/2022062717/56649e4c5503460f94b419b6/html5/thumbnails/18.jpg)
![Page 19: The approach to adopting new equipment, drugs and techniques into practice Martin Jöhr Paediatric Anaesthesia Department of Anaesthesia Kantonsspital.](https://reader035.fdocuments.in/reader035/viewer/2022062717/56649e4c5503460f94b419b6/html5/thumbnails/19.jpg)
2006 Sono Site 2006 Sono Site2006 modern equipment becomes widely available
2006 modern equipment becomes widely available
![Page 20: The approach to adopting new equipment, drugs and techniques into practice Martin Jöhr Paediatric Anaesthesia Department of Anaesthesia Kantonsspital.](https://reader035.fdocuments.in/reader035/viewer/2022062717/56649e4c5503460f94b419b6/html5/thumbnails/20.jpg)
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 …
![Page 21: The approach to adopting new equipment, drugs and techniques into practice Martin Jöhr Paediatric Anaesthesia Department of Anaesthesia Kantonsspital.](https://reader035.fdocuments.in/reader035/viewer/2022062717/56649e4c5503460f94b419b6/html5/thumbnails/21.jpg)
2013 an established technique2013 an established technique
Many courses and workshops
Procedures well defined
Institutionalized teaching
Young people => success
![Page 22: The approach to adopting new equipment, drugs and techniques into practice Martin Jöhr Paediatric Anaesthesia Department of Anaesthesia Kantonsspital.](https://reader035.fdocuments.in/reader035/viewer/2022062717/56649e4c5503460f94b419b6/html5/thumbnails/22.jpg)
Luyet C et al. Anesthesiology Research and Practice (2010) 309462
USNS
Brachial plexus block
With and without ultrasound
![Page 23: The approach to adopting new equipment, drugs and techniques into practice Martin Jöhr Paediatric Anaesthesia Department of Anaesthesia Kantonsspital.](https://reader035.fdocuments.in/reader035/viewer/2022062717/56649e4c5503460f94b419b6/html5/thumbnails/23.jpg)
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
![Page 24: The approach to adopting new equipment, drugs and techniques into practice Martin Jöhr Paediatric Anaesthesia Department of Anaesthesia Kantonsspital.](https://reader035.fdocuments.in/reader035/viewer/2022062717/56649e4c5503460f94b419b6/html5/thumbnails/24.jpg)
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
![Page 25: The approach to adopting new equipment, drugs and techniques into practice Martin Jöhr Paediatric Anaesthesia Department of Anaesthesia Kantonsspital.](https://reader035.fdocuments.in/reader035/viewer/2022062717/56649e4c5503460f94b419b6/html5/thumbnails/25.jpg)
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
![Page 26: The approach to adopting new equipment, drugs and techniques into practice Martin Jöhr Paediatric Anaesthesia Department of Anaesthesia Kantonsspital.](https://reader035.fdocuments.in/reader035/viewer/2022062717/56649e4c5503460f94b419b6/html5/thumbnails/26.jpg)
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
![Page 27: The approach to adopting new equipment, drugs and techniques into practice Martin Jöhr Paediatric Anaesthesia Department of Anaesthesia Kantonsspital.](https://reader035.fdocuments.in/reader035/viewer/2022062717/56649e4c5503460f94b419b6/html5/thumbnails/27.jpg)
ET
Jöhr M et al. Paediatr Anaesth (2010) 20: 105
5 months, 6.5 kg
![Page 28: The approach to adopting new equipment, drugs and techniques into practice Martin Jöhr Paediatric Anaesthesia Department of Anaesthesia Kantonsspital.](https://reader035.fdocuments.in/reader035/viewer/2022062717/56649e4c5503460f94b419b6/html5/thumbnails/28.jpg)
ET
Jöhr M et al. Paediatr Anaesth (2010) 20: 105
5 months, 6.5 kg
![Page 29: The approach to adopting new equipment, drugs and techniques into practice Martin Jöhr Paediatric Anaesthesia Department of Anaesthesia Kantonsspital.](https://reader035.fdocuments.in/reader035/viewer/2022062717/56649e4c5503460f94b419b6/html5/thumbnails/29.jpg)
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
![Page 30: The approach to adopting new equipment, drugs and techniques into practice Martin Jöhr Paediatric Anaesthesia Department of Anaesthesia Kantonsspital.](https://reader035.fdocuments.in/reader035/viewer/2022062717/56649e4c5503460f94b419b6/html5/thumbnails/30.jpg)
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
?
![Page 31: The approach to adopting new equipment, drugs and techniques into practice Martin Jöhr Paediatric Anaesthesia Department of Anaesthesia Kantonsspital.](https://reader035.fdocuments.in/reader035/viewer/2022062717/56649e4c5503460f94b419b6/html5/thumbnails/31.jpg)
cricoid pressure
Available technology is not usedAvailable technology is not used
![Page 32: The approach to adopting new equipment, drugs and techniques into practice Martin Jöhr Paediatric Anaesthesia Department of Anaesthesia Kantonsspital.](https://reader035.fdocuments.in/reader035/viewer/2022062717/56649e4c5503460f94b419b6/html5/thumbnails/32.jpg)
![Page 33: The approach to adopting new equipment, drugs and techniques into practice Martin Jöhr Paediatric Anaesthesia Department of Anaesthesia Kantonsspital.](https://reader035.fdocuments.in/reader035/viewer/2022062717/56649e4c5503460f94b419b6/html5/thumbnails/33.jpg)
ventilator
teacher
trainee
![Page 34: The approach to adopting new equipment, drugs and techniques into practice Martin Jöhr Paediatric Anaesthesia Department of Anaesthesia Kantonsspital.](https://reader035.fdocuments.in/reader035/viewer/2022062717/56649e4c5503460f94b419b6/html5/thumbnails/34.jpg)
Videolaryngoscopy
• guide and control• reach success
7 weeks old boy 5.6 kg
![Page 35: The approach to adopting new equipment, drugs and techniques into practice Martin Jöhr Paediatric Anaesthesia Department of Anaesthesia Kantonsspital.](https://reader035.fdocuments.in/reader035/viewer/2022062717/56649e4c5503460f94b419b6/html5/thumbnails/35.jpg)
Videolaryngoscopy
• guide and control• reach success
7 weeks old boy 5.6 kg
![Page 36: The approach to adopting new equipment, drugs and techniques into practice Martin Jöhr Paediatric Anaesthesia Department of Anaesthesia Kantonsspital.](https://reader035.fdocuments.in/reader035/viewer/2022062717/56649e4c5503460f94b419b6/html5/thumbnails/36.jpg)
7 weeks old boy 5.6 kg
Videolaryngoscopy
• guide and control• reach success
![Page 37: The approach to adopting new equipment, drugs and techniques into practice Martin Jöhr Paediatric Anaesthesia Department of Anaesthesia Kantonsspital.](https://reader035.fdocuments.in/reader035/viewer/2022062717/56649e4c5503460f94b419b6/html5/thumbnails/37.jpg)
Schüpfer G, Jöhr M. Paediatr Anaesth (2005) 15: 461-469
C
W
Institutional learning curveInstitutional learning curve
![Page 38: The approach to adopting new equipment, drugs and techniques into practice Martin Jöhr Paediatric Anaesthesia Department of Anaesthesia Kantonsspital.](https://reader035.fdocuments.in/reader035/viewer/2022062717/56649e4c5503460f94b419b6/html5/thumbnails/38.jpg)
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
![Page 39: The approach to adopting new equipment, drugs and techniques into practice Martin Jöhr Paediatric Anaesthesia Department of Anaesthesia Kantonsspital.](https://reader035.fdocuments.in/reader035/viewer/2022062717/56649e4c5503460f94b419b6/html5/thumbnails/39.jpg)
1. Learn (lectures)
2. Train (simulators)
3. Practice (peer)
![Page 40: The approach to adopting new equipment, drugs and techniques into practice Martin Jöhr Paediatric Anaesthesia Department of Anaesthesia Kantonsspital.](https://reader035.fdocuments.in/reader035/viewer/2022062717/56649e4c5503460f94b419b6/html5/thumbnails/40.jpg)
• General remarks
• Drugs and Equipment
• New concepts
• Conclusions
• “new in the focus”• “contagious ideas”
![Page 41: The approach to adopting new equipment, drugs and techniques into practice Martin Jöhr Paediatric Anaesthesia Department of Anaesthesia Kantonsspital.](https://reader035.fdocuments.in/reader035/viewer/2022062717/56649e4c5503460f94b419b6/html5/thumbnails/41.jpg)
Trauma, surgery, illness
=> ADH↑ => water is retained
![Page 42: The approach to adopting new equipment, drugs and techniques into practice Martin Jöhr Paediatric Anaesthesia Department of Anaesthesia Kantonsspital.](https://reader035.fdocuments.in/reader035/viewer/2022062717/56649e4c5503460f94b419b6/html5/thumbnails/42.jpg)
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
![Page 43: The approach to adopting new equipment, drugs and techniques into practice Martin Jöhr Paediatric Anaesthesia Department of Anaesthesia Kantonsspital.](https://reader035.fdocuments.in/reader035/viewer/2022062717/56649e4c5503460f94b419b6/html5/thumbnails/43.jpg)
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
![Page 44: The approach to adopting new equipment, drugs and techniques into practice Martin Jöhr Paediatric Anaesthesia Department of Anaesthesia Kantonsspital.](https://reader035.fdocuments.in/reader035/viewer/2022062717/56649e4c5503460f94b419b6/html5/thumbnails/44.jpg)
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
![Page 45: The approach to adopting new equipment, drugs and techniques into practice Martin Jöhr Paediatric Anaesthesia Department of Anaesthesia Kantonsspital.](https://reader035.fdocuments.in/reader035/viewer/2022062717/56649e4c5503460f94b419b6/html5/thumbnails/45.jpg)
Eur J Anaesthesiol (2011) 28: 637-639
Fluid therapyFluid therapy
![Page 46: The approach to adopting new equipment, drugs and techniques into practice Martin Jöhr Paediatric Anaesthesia Department of Anaesthesia Kantonsspital.](https://reader035.fdocuments.in/reader035/viewer/2022062717/56649e4c5503460f94b419b6/html5/thumbnails/46.jpg)
Dubois MC et al. Paediatr Anaesth (1992) 2: 99-104
![Page 47: The approach to adopting new equipment, drugs and techniques into practice Martin Jöhr Paediatric Anaesthesia Department of Anaesthesia Kantonsspital.](https://reader035.fdocuments.in/reader035/viewer/2022062717/56649e4c5503460f94b419b6/html5/thumbnails/47.jpg)
Sümpelmann R et al. Paediatr Anaesth (2010) 20: 977-81
![Page 48: The approach to adopting new equipment, drugs and techniques into practice Martin Jöhr Paediatric Anaesthesia Department of Anaesthesia Kantonsspital.](https://reader035.fdocuments.in/reader035/viewer/2022062717/56649e4c5503460f94b419b6/html5/thumbnails/48.jpg)
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
![Page 49: The approach to adopting new equipment, drugs and techniques into practice Martin Jöhr Paediatric Anaesthesia Department of Anaesthesia Kantonsspital.](https://reader035.fdocuments.in/reader035/viewer/2022062717/56649e4c5503460f94b419b6/html5/thumbnails/49.jpg)
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
![Page 50: The approach to adopting new equipment, drugs and techniques into practice Martin Jöhr Paediatric Anaesthesia Department of Anaesthesia Kantonsspital.](https://reader035.fdocuments.in/reader035/viewer/2022062717/56649e4c5503460f94b419b6/html5/thumbnails/50.jpg)
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
![Page 51: The approach to adopting new equipment, drugs and techniques into practice Martin Jöhr Paediatric Anaesthesia Department of Anaesthesia Kantonsspital.](https://reader035.fdocuments.in/reader035/viewer/2022062717/56649e4c5503460f94b419b6/html5/thumbnails/51.jpg)
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
[email protected]@luks.ch
![Page 52: The approach to adopting new equipment, drugs and techniques into practice Martin Jöhr Paediatric Anaesthesia Department of Anaesthesia Kantonsspital.](https://reader035.fdocuments.in/reader035/viewer/2022062717/56649e4c5503460f94b419b6/html5/thumbnails/52.jpg)
Ventilation by mask can cause problems
![Page 53: The approach to adopting new equipment, drugs and techniques into practice Martin Jöhr Paediatric Anaesthesia Department of Anaesthesia Kantonsspital.](https://reader035.fdocuments.in/reader035/viewer/2022062717/56649e4c5503460f94b419b6/html5/thumbnails/53.jpg)
CAVE: gastric distensionCAVE: gastric distension
![Page 54: The approach to adopting new equipment, drugs and techniques into practice Martin Jöhr Paediatric Anaesthesia Department of Anaesthesia Kantonsspital.](https://reader035.fdocuments.in/reader035/viewer/2022062717/56649e4c5503460f94b419b6/html5/thumbnails/54.jpg)
Respiratory insufficiency
CAVE: gastric distensionCAVE: gastric distension
![Page 55: The approach to adopting new equipment, drugs and techniques into practice Martin Jöhr Paediatric Anaesthesia Department of Anaesthesia Kantonsspital.](https://reader035.fdocuments.in/reader035/viewer/2022062717/56649e4c5503460f94b419b6/html5/thumbnails/55.jpg)
Since 2002 with the anaesthesia ventilator
![Page 56: The approach to adopting new equipment, drugs and techniques into practice Martin Jöhr Paediatric Anaesthesia Department of Anaesthesia Kantonsspital.](https://reader035.fdocuments.in/reader035/viewer/2022062717/56649e4c5503460f94b419b6/html5/thumbnails/56.jpg)
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
![Page 57: The approach to adopting new equipment, drugs and techniques into practice Martin Jöhr Paediatric Anaesthesia Department of Anaesthesia Kantonsspital.](https://reader035.fdocuments.in/reader035/viewer/2022062717/56649e4c5503460f94b419b6/html5/thumbnails/57.jpg)
The "educated hand". Can anesthesiologists assess changes in neonatal pulmonary compliance manually?
Spears RS Jr et al. Anesthesiology (1991) 75: 693-6
![Page 58: The approach to adopting new equipment, drugs and techniques into practice Martin Jöhr Paediatric Anaesthesia Department of Anaesthesia Kantonsspital.](https://reader035.fdocuments.in/reader035/viewer/2022062717/56649e4c5503460f94b419b6/html5/thumbnails/58.jpg)
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
![Page 59: The approach to adopting new equipment, drugs and techniques into practice Martin Jöhr Paediatric Anaesthesia Department of Anaesthesia Kantonsspital.](https://reader035.fdocuments.in/reader035/viewer/2022062717/56649e4c5503460f94b419b6/html5/thumbnails/59.jpg)
With the anaesthesia ventilator => a new strategy
![Page 60: The approach to adopting new equipment, drugs and techniques into practice Martin Jöhr Paediatric Anaesthesia Department of Anaesthesia Kantonsspital.](https://reader035.fdocuments.in/reader035/viewer/2022062717/56649e4c5503460f94b419b6/html5/thumbnails/60.jpg)
• General remarks
• Drugs and Equipment
• New concepts
• Conclusions
![Page 61: The approach to adopting new equipment, drugs and techniques into practice Martin Jöhr Paediatric Anaesthesia Department of Anaesthesia Kantonsspital.](https://reader035.fdocuments.in/reader035/viewer/2022062717/56649e4c5503460f94b419b6/html5/thumbnails/61.jpg)
• 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
![Page 62: The approach to adopting new equipment, drugs and techniques into practice Martin Jöhr Paediatric Anaesthesia Department of Anaesthesia Kantonsspital.](https://reader035.fdocuments.in/reader035/viewer/2022062717/56649e4c5503460f94b419b6/html5/thumbnails/62.jpg)
![Page 63: The approach to adopting new equipment, drugs and techniques into practice Martin Jöhr Paediatric Anaesthesia Department of Anaesthesia Kantonsspital.](https://reader035.fdocuments.in/reader035/viewer/2022062717/56649e4c5503460f94b419b6/html5/thumbnails/63.jpg)
![Page 64: The approach to adopting new equipment, drugs and techniques into practice Martin Jöhr Paediatric Anaesthesia Department of Anaesthesia Kantonsspital.](https://reader035.fdocuments.in/reader035/viewer/2022062717/56649e4c5503460f94b419b6/html5/thumbnails/64.jpg)
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