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