4. 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

6. 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

7. ECG and NIBP plus careful clinical evaluation Monitoring

8. Eur J Anaesthesiol (2011) 28: 637-639 Hypotonic solutions: glucose 5% with sodium 30 mmol/l Fluid therapy

9. Postoperative care

10. There is a continuous change over the time 1974 2012

11. Ether Halothane Enflurane Alcuronium Succinylcholine Pethidine Morphine Tetracaine There is a continuous change over the time

12. Sevoflurane Desflurane Propofol Remifentanil Atracurium Rocuronium Sugammadex Ropivacaine There is a continuous change over the time

13. Sevoflurane Desflurane Propofol Remifentanil Atracurium Rocuronium Sugammadex Ropivacaine There is a continuous change over the time agitated children laryngospasm hypotension, PRIS insufficient pain relief

14. General remarks Drugs and equipment New concepts Conclusions available affordable

15. The introduction of ultrasound 1. Theory theoretical knowledge (lectures) knowledge of published experience 2. Training (simulators) phantoms cadavers 3. Practice (patients) supervised guided

16. 1. Theory theoretical knowledge (lectures) knowledge of published experience 2. Training (simulators) phantoms cadavers 3. Practice (patients) supervised guided

17. (1994) 2000 Site Rite ®

19. 2006 Sono Site 2006 modern equipment becomes widely available

20. 2006 Sono Site 2006 modern equipment becomes widely available … we enthusiastically learned it by trial and error …

21. 2013 an established technique Many courses and workshops Procedures well defined Institutionalized teaching Young people => success

22. Luyet C et al. Anesthesiology Research and Practice (2010) 309462 US NS Brachial plexus block With and without ultrasound

23. 2002 NICE recommended ultrasound "It's nice to see in the dark" Scott DHT Br J Anaesth (2003) 90: 269-272 Available technology is not used

24. Grebenik CR et al. (Oxford) Br J Anaesth (2004) 92: 827-830 "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 - 24.6 kg Meta-analysis Sigaut S et al. Paediatr Anaesth (2009) 19: 1199-206

25. Evidence-based medicine Hind D et al. BMJ (2003) 327: 361-368 complications > 1 attempt failure relative risk meta-analysis data up to 2001 internal jugular 18 papers 1646 patients

26. 100 0 20 40 60 80 100 20 minutes ultrasound % inserted catheters Hosokawa K et al. Anesthesiology (2007) 107: 720-724 Visual approach 60 neonates and infants < 7.5 kg US => landmarks US real-time

27. ET Jöhr M et al. Paediatr Anaesth (2010) 20: 105 5 months, 6.5 kg

28. ET Jöhr M et al. Paediatr Anaesth (2010) 20: 105 5 months, 6.5 kg

29. Abrahams MS et al. Br J Anaesth (2010) 102: 408-17 Meta-analysis 13 papers 946 patients vascular puncture failure RR faster longer With ultrasound => less failures Evidence-based Medicine

30. 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 ?

31. cricoid pressure Available technology is not used

33. ventilator teacher trainee

34. Videolaryngoscopy guide and control reach success 7 weeks old boy 5.6 kg

35. Videolaryngoscopy guide and control reach success 7 weeks old boy 5.6 kg

36. 7 weeks old boy 5.6 kg Videolaryngoscopy guide and control reach success

37. Schüpfer G, Jöhr M. Paediatr Anaesth (2005) 15: 461-469 C W Institutional learning curve

38. Schüpfer G, Jöhr M. Paediatr Anaesth (2005) 15: 465-469 number of patients success rate Psoas compartment block 100 patients 5.9 -106 kg Success first attempt no complication analgesia

39. 1. Learn (lectures) 2. Train (simulators) 3. Practice (peer)

40. General remarks Drugs and Equipment New concepts Conclusions “new in the focus” “contagious ideas”

41. Trauma, surgery, illness => ADH↑ => water is retained

42. Pfenninger J. Paediatr Anaesth (1992) 2: 85-87 within 8 years: 8 severe cases => 3 deaths Hyponatremia is a lethal threat Arieff AI et al. BMJ (1992) 304: 1218-1222 24'412 children, within 3 years: 83 cases => 9 deaths

43. 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 threat NaCl 0.9% measuring Na

44. Duke T, Molyneux EM. Lancet (2003) 362: 1320-1323 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

45. Eur J Anaesthesiol (2011) 28: 637-639 Fluid therapy

46. Dubois MC et al. Paediatr Anaesth (1992) 2: 99-104

47. Sümpelmann R et al. Paediatr Anaesth (2010) 20: 977-81

48. 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

49. Doherty C et al. Pediatrics (2012) 129: 916-924 Tenfold medication errors: 5 years’ experience at a university-affiliated paediatric hospital 252 cases within 5 years once a week Dosing errors prescription – administration

50. Jani YH et al. Qual Saf Health Care (2010) 19: 337-340 % Paediatric dosing errors before and after electronic prescribing before after The school of pharmacy University of London Dosing errors prescription – administration

51. On the ward and on the PICU Electronic prescriptions prescription cross check and administration physician patient thomas.berger@luks.ch

52. Ventilation by mask can cause problems

53. CAVE: gastric distension

54. Respiratory insufficiency CAVE: gastric distension

55. Since 2002 with the anaesthesia ventilator

56. 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: 260-263 Ventilator derived mask ventilation … Tracy MB et al. Arch Dis Child Fetal Neonatal Ed (2011) 296: F201-5

57. The "educated hand". Can anesthesiologists assess changes in neonatal pulmonary compliance manually? Spears RS Jr et al. Anesthesiology (1991) 75: 693-6

58. 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 y PIP increasing 10-15-20-25 cm H 2 O small children more prone to gastric distension < 15 cm H 2 O problems rarely occurred

59. With the anaesthesia ventilator => a new strategy

60. General remarks Drugs and Equipment New concepts Conclusions

61. 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

64. Visual approach Hosokawa K et al. Anesthesiology (2007) 107: 720-724 60 neonates and infants < 7.5 kg US => landmarks US real-time Kyoto