SAFETOTS Sichere Anästhesie für alle Kinder
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1 SAFETOTS Sichere Anästhesie für alle Kinder Pädiatrische Traunseeklausur Mai 2018 Gmunden (A) Prof. Dr. med. Markus Chefarzt Anästhesieabteilung, Universitäts-Kinderspital Zürich Extraordinarius für Kinderanästhesie Universität Zürich
2 Background
3 Background Rappaport B NEJM 2011
4 Safe Anaesthesia in Children What is safe in paediatric anaesthesia? We don t know it!
5 Safe Anaesthesia in Children What is unsafe in Paediatric Anaesthesia? We know it! very well
6 What is the Risk in Paed Anaesth? Paediatric Anaesthesia is a high risk area! Children undergoing anaesthesia have an increased perioperative risk as compared to the adults Up to 5-10 % perioperative complications Mainly respiratory events (53-77 %) Paterson and Waterhouse Pediatr Anesth 2011 Habre W et al Lancet Respir Med 2017
7 What is the Risk in Paed Anaesth? Cardiac Arrest Infants 19-24/ all 1-7/ Paterson and Waterhouse Pediatr Anesth 2011
8 What is the Risk in Paed Anaesth? Cardiac Arrest Infants 19-24/ all 1-7/ % Incidence of Cardiac Arrest in Infants/Newborns Nunnally ME Anesth Analg 2015
9 What is the Risk in Paed Anaesth? Cardiac Arrest in Paediatric Anaesthesia Newborns & Infants 55 % Mortality in Newborns 72 % Previously Healthy Children > 30 % Morray JP Anesthesiology 2000
10 What is the Risk in Paed Anaesth? Mortality Children / Adults 0.07 / Becke K Anaesthesist 2014
11 What is the Risk in Paed Anaesth? Why that? Low or no respiratory reserves Functional airway obstruction / high CC Low circulatory reserves / bradycardia Difficult vascular access Time, experience and skills becomes crucial
12 What are the Risks in Paed Anaesth? Patient related risks (age, comorbidity) Surgery related risks (emergency, ENT) Anaesthesia related risks Anaesthetist and institutional (in)-competence The anaesthetist / anaesthesia team is so far the only evidence based anaesthesia related risk factor in paediatric anaesthesia Becke K Anaesthesist 2014
13 What is dangerous in Paed Anaesth? Inexperience in Paediatric Anaesthesia Non-paediatric anaesthesiologists provoke higher rates of bradycardia in children than paediatric anaesthetists 2.12 % versus 0.82 % (p < ) Keenan RL Anesthesiology 1994
14 What is dangerous in Paed Anaesth? Inexperience in Paediatric Anaesthesia Non-paediatric anaesthesiologists provoke higher rates of cardiac arrests in children than paediatric anaesthesiologists 4:2033 versus 0:2310 (p < 0.048) 4: : (1-7:10 000) Keenan RL J Clin Anesth 1991
15 What is dangerous in Paed Anaesth? Occasional Paediatric Anaesthesia Severe complications (1:500; n= 351/ ) < 100 Anaesthesias / year 7.0 +/ per 1000 * Anaesthesias / year 2.8 +/ per 1000 * > 200 Anaesthesias / year 1.3 +/- 4.3 per 1000 * p<0.05 compared to > 200 anaesthesias / year Auroy Y Anesth Analg 1997
16 What is dangerous in Paed Anaesth? Occasional Paediatric Anaesthesia Severe complications in infants undergoing inguinal herniotomy GA n= % severe complications Retrospective study over 7 years 52 anaesthetists involved 0.45 GA in an infant hernia / per anaesthesiologist / year 1 GA in an infant / per anaesthesiologist / year Fischer R Doctoral Thesis - University of Aachen 2009
17 What is dangerous in Paed Anaesth? Economic Pressure Lack of even basic staffing Lack of logistic resources for paediatric anaesthesia
18 What is dangerous in Paed Anaesth? Marketing & Narcisstic Pressures Anaesthesia departments with less than anaesthetics in children per year provide anaesthesia in very small preterm neonates for extensive surgical procedures
19 What is dangerous in Paed Anaesth? Academic Pressures Scientific writing but not dedicated teaching and supervising of residents is honoured 19 operating rooms 4 staff for supervising planned 1 staff available / 3 staffs on scientific work Survival Medicine in (Paediatric) Anaesthesia
20 What is unsafe in Paed Anaesth? Trespassing safety limits Leaving the normal Neglecting the normal Accepting the abnormal
21 What are the critical issues influencing best outcome in children? Weiss M et al Curr Opinion Anesthesiol 2015
22 What is critical in Paed Anaesth? Fear % of children suffer from fear during anaesthesia mainly in the induction period increased pain / need for analgesics increased incidence of emergence delirium increased postoperative behavioural changes Kain ZN Anesthesiology Clin N Am 2005
23 What is critical in Paed Anaesth? Hypovolaemia Prolonged fasting times Missed perioperative fluid / volume deficits Lack of sufficient venous access Circulatory failure is the main reason for cardiac arrest in paediatric anaesthesia (POCA-study) Bhanaker SM Anesthesiology 2007
24 What is critical in Paed Anaesth? Hypotension
25 What is critical in Paed Anaesth? Hypotension Systolic Threshold Values for Therapy Survey SPA versus APA Nafiu OO Pediatr Anesth 2009
26 What is unsafe in Paed Anaesth? Hypotension Definitions Pediatric Advanced Life Support - systolic < 60 mm Hg in neonates Brain Trauma Foundation Guidelines - systolic < 70 mm Hg + 2 (age in yrs) British Association of Perinatal Medicine - MAP < infant s gestation age in weeks AHA Circulation 2000
27 What is unsafe in Paed Anaesth? Hypotension Incidence Pre-incisional hypotension (PIH) < 5 th percentile age related SBP children with GA Age 1-17 years (newborns and infants not included!!) 35% incidence of PIH Nafiu OO Pediatr Anesth 2008
28 What is unsafe in Paed Anaesth? Hypotension Clinical Consequences McCann ME Pediatrics 2014
29 What is unsafe in Paed Anaesth? Hypotension Clinical Consequences 6 infants, aged weeks Duration of anaesthesia min Sevoflurane, Propofol, Remifentanil Median MAP: 31.6 to 38.3 mmhg 4-26 hits below 30 mmhg MAP Onset of cerebral seizures within 25 h in all 6 infants McCann ME Pediatrics 2014
30 What is unsafe in Paed Anaesth? Hypocapnia Zhou W Worlds J Pediatr 2008
31 What is unsafe in Paed Anaesth? Hypocapnia in Newborns Periventricular leukomalacia Intraventricular haemorrhage Cerebral palsy Cognition development disorder Zhou W Worlds J Pediatr 2008
32 What is unsafe in Paed Anaesth? Hypocapnia in Anaesthesia Mild: kpa ETCO 2 Moderate: kpa ETCO 2 Severe: < 3.3 kpa ETCO 2 Pappas A J Pediatr 2011
33 What is unsafe in Paed Anaesth? PaCO 2 / ETCO 2 - Monitoring ETCO 2 -monitoring not reliable Uncuffed tracheal tubes with leakage Poor correlation to PaCO 2 Pappas A J Pediatr 2011
34 What is unsafe in Paed Anaesth? Negative PaCO 2 -ETCO 2 Gaps Onodi C et al Anaesthesia 2017
35 What is unsafe in Paed Anaesth? PaCO 2 -ETCO 2 Gaps Mild hypocapnia kpa ETCO 2 Negative gap of 1 kpa kpa PaCO 2
36 What is unsafe in Paed Anaesth? Hypotension and Hypocapnia Ringer S Pediatr Anesth 2016
37 What is unsafe in Paed Anaesth? Hypotension and Hypocapnia Hypotension and hypocapnia alone resulted in signs of metabolic disturbances despite the absence of detectable cerebral perfusion alterations Ringer S Pediatr Anesth 2016
38 What is unsafe in Paed Anaesth? Hypotension and Hypocapnia The combination of HT and HC during sevoflurane anaesthesia resulted in alteration of cerebral perfusion with signs of neuronal dysfunction and early neuronal ischemia. Ringer S Pediatr Anesth 2016
39 What is unsafe in Paed Anaesth? Perioperative Hyponatraemia
40 What is unsafe in Paed Anaesth? Hyponatraemia due to hypotonic fluid therapy Death or permanent brain damage in healthy children Brain swelling Transtentorial herniation Vegetative state Brain death Death Arieff AI BMJ 1992
41 What is unsafe in Paed Anaesth? Hyponatraemia due to hypotonic fluid therapy Postoperative hyponatraemic encephalopathy Estimated deaths / year US the syndrome can be prevented by the perioperative administration of primarily isotonic fluids to patients Arieff AI Pediatr Anesth 1998
42 What is unsafe in Paed Anaesth? Hypoxaemia / Bradycardia
43 What is unsafe in Paed Anaesth? Hypoxaemia - Incidence degraaff JC - Anesth Analg 2013
44 What is unsafe in Paed Anaesth? Hypoxaemia / Bradycardia Poets CF - JAMA 2015
45 What is unsafe in Paed Anaesth? Hypoxaemia / Bradycardia Poets CF - JAMA 2015
46 What is unsafe in Paed Anaesth? Hypoglycaemia Hyperglycaemia Seizures Cerebral damage Burns CM et al - Pediatrics 2008 / Bush GH Pediatr Anesth 1995
47 What is unsafe in Paed Anaesth? Hypothermia Coagulation disorder Intraoperative hyperglycaemia Postoperative hypoglycaemia Postoperative apnoea Wound infections Sessler DI Anesthesiology 2001
48 What is unsafe in Paed Anaesth? Pain Taddio A Lancet 1997
49 Why is it beeing ignored? Is it because it is scientifically not interesting and academically not enough lucrative? we already know the answer? the answers are uncomfortable? it would be a shame for the workman?
50 What about Anaesthetics Neurotoxicity Primarily a laboratory finding Laboratory conditions are not clinically representative Not a significant clinical problem Animal research not any longer justified because of lack of clinical relevance
51 What about Anaesthetics Neurotoxicity New clinical studies GAS Study Lancet 2016 PANDA Study JAMA 2016 Manitoba Study Anesthesiology 2016 Swedish Cohort Study JAMA Pediatrics 2016 Becke K Deutsch Aerzteblatt 2017
52 What about Anaesthetics Neurotoxicity Swedish Cohort Study Month of birth Education of the mother Gender Surgery in children > 3 years Glatz P Jama Pediatrics 2016
53 What about Anaesthetics Neurotoxicity Obstructive Sleep Apnoe Syndrome (OSAS) > 50% of Children 2-7 years are ENT Children Often with known / unknown OSAS many antibiotics / infections OSAS well recognized to cause behavioural and neurocognitive dysfunction in preschool children Landau YE Pediatr Pulmonology 2012
54 What about Anaesthetics Neurotoxicity European Statement ESA ESPA EACTA EUROSTAR Quality and conduct of anaesthesia is more relevant than the drug Hansen TG. - Paadiatr Anaesth 2017 Hansen TG - Eur J Anaesthesiol 2017
55 What about Anaesthetics Neurotoxicity Anaesthetists rather the anaesthetics are the threat for baby brains Weiss M et al Paediatr Anaesth 2013
56 Defining Safe Paed Anaesth
57 Defining the WHO WHERE What WHEN HOW
58 the who Paediatric Anaesthetists with profound education experience and training in all techniques supervised trainees
59 the where Institutional competence paediatric anaesthetists nurse anaesthetists perioperative logistics for small children regulations, SOPs, workshops case load
60 the what Newborns, infants, small kids specialized centers Routine surgery in healthy older kids regional centers Sick kids, special needs, specialized surgery specialized centers
61 the when Balance The higher risk for complications in smaller children and risks and consequences of delaying surgery or diagnostic interventions on the childs outcome and wellbeeing
62 The HOW Weiss M et al - Curr Opinion of Anesthesiol 2015
63 The 10-N Quality Anaesthesia n = 435 anesthetics in neonates 5 (3-6 IQR) rule deviations per case only 11 cases had no rule deviation Görges M Paediatr Anaesth 2016
64 Safe Anaesthesia For Every Tot - Initiative SAFETOTS is a registered Trademark Weiss M Curr Opin Anesthesiol 2015
65 Safe Anaesthesia For Every Tot - Initiative SAFETOTS is a registered Trademark Weiss M Curr Opin Anesthesiol 2015
66 Take home The discussion about neurotoxicity of anaesthetics in young children is distracting from the real safety issues in paediatric anaesthesia and does not really improve safety in children undergoing general anaesthesia
67 67 Take home Anaesthesiologists rather than the anaesthetics are the threat to baby brains
68 68 Take home The Who The Where The What The When The how
69 69 Take home 10-N Quality
70 70 Take home
71
72 SAFETOTS Sichere Anästhesie für alle Kinder Besten Dank für Ihre Aufmerksamkeit
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