The approach to adopting new equipment, drugs and techniques into practice Martin Jöhr Paediatric Anaesthesia Department of Anaesthesia Kantonsspital 6000 Luzern 16, Switzerland

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 Airway management and ventilation

ECG and NIBP plus careful clinical evaluation Monitoring

Eur J Anaesthesiol (2011) 28: Hypotonic solutions: glucose 5% with sodium 30 mmol/l Fluid therapy

Postoperative care

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 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 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 Sono Site 2006 modern equipment becomes widely available

2006 Sono Site 2006 modern equipment 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

Luyet C et al. Anesthesiology Research and Practice (2010) US NS Brachial plexus block With and without ultrasound

2002 NICE recommended ultrasound "It's nice to see in the dark" Scott DHT Br J Anaesth (2003) 90: Available technology is not used

Grebenik CR et al. (Oxford) Br J Anaesth (2004) 92: "NICE guidelines for CVC in children Is the evidence base sufficient?" Consultant paediatric anaesthetists landmark (n = 65) ultrasound (n = 59) Neonates to 8 y; 2.0 kg kg Meta-analysis Sigaut S et al. Paediatr Anaesth (2009) 19:

Evidence-based medicine Hind D et al. BMJ (2003) 327: complications > 1 attempt failure relative risk meta-analysis data up to 2001 internal jugular 18 papers 1646 patients

minutes ultrasound % inserted catheters Hosokawa K et al. Anesthesiology (2007) 107: Visual approach 60 neonates and infants < 7.5 kg US => landmarks US real-time

ET Jöhr M et al. Paediatr Anaesth (2010) 20: months, 6.5 kg

ET Jöhr M et al. Paediatr Anaesth (2010) 20: months, 6.5 kg

Abrahams MS et al. Br J Anaesth (2010) 102: Meta-analysis 13 papers 946 patients vascular puncture failure RR faster longer With ultrasound => less failures Evidence-based Medicine

EBM – “lost in translation” missing equipment high cost missing appreciation Lenfant C: Clinical research to clinical practice – lost in translation? NEJM (2003) 349: ?

cricoid pressure Available 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: C W Institutional learning curve

Schüpfer G, Jöhr M. Paediatr Anaesth (2005) 15: number of patients success rate Psoas compartment block 100 patients 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: within 8 years: 8 severe cases => 3 deaths Hyponatremia is a lethal threat Arieff AI et al. BMJ (1992) 304: '412 children, within 3 years: 83 cases => 9 deaths

Moritz ML, Ayus JC. Pediatrics (2003) 111: > 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 threat NaCl 0.9% measuring Na

Duke T, Molyneux EM. Lancet (2003) 362: Intravenous 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 threat

Eur J Anaesthesiol (2011) 28: Fluid therapy

Dubois MC et al. Paediatr Anaesth (1992) 2:

Sümpelmann R et al. Paediatr Anaesth (2010) 20:

Niesters M et al. Leiden Br J Anaesth (2013) 110 Feb : 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

Doherty C et al. Pediatrics (2012) 129: Tenfold medication errors: 5 years’ experience at a university-affiliated paediatric hospital 252 cases within 5 years once a week Dosing errors prescription – administration

Jani YH et al. Qual Saf Health Care (2010) 19: % Paediatric dosing errors before and after electronic prescribing before after The school of pharmacy University of London Dosing errors prescription – administration

On the ward and on the PICU Electronic prescriptions prescription cross check and administration physician patient

Ventilation by mask can cause problems

CAVE: gastric distension

Respiratory insufficiency CAVE: gastric distension

Since 2002 with the anaesthesia ventilator

Ventilator derived mask ventilation before endotracheal intubation PCV (pressure controlled ventilation) PIP 13 cm H 2 O PEEP 3 cm H 2 O Rateage dependent Von Goedecke A et al. Anesth Analg (2004) 98: 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: children, 1-16 y PIP increasing cm H 2 O small children more prone to gastric distension < 15 cm H 2 O 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. Conclusions

Visual approach Hosokawa K et al. Anesthesiology (2007) 107: neonates and infants < 7.5 kg US => landmarks US real-time Kyoto