Neonatal ResuscitationA Canadian Perspective

Andrew James MBChB MBI FRACP FRCPCAssociate Clinical Director, NICU

The Hospital for Sick Children, TorontoAssociate Professor, Department of Paediatrics

University of Toronto, Toronto, ON, Canada

Fourth Annual NRP Conference, Shenzhen, China, October 19-22, 2010

Neonatal intensive care unit

Advanced multidisciplinary practice

Regionalised Network . . .

Provincial system established in 1970’s

Levels of care defined - I to III

SickKids epicentre coordinating level III activity

prematurity perinatal centres

surgical, cardiac, complex newborns SickKids

SickKids only outborn unit in region

Referral NICU for 75,000 deliveries

Ability to provide level III and IV services

Cong Anom

GI

Cardiac

NeuroResp

Metabolic/ Other

Full term infants (51%)

CongAnom

GI

Cardiac

NeuroResp

Metabolic / Other

Preterm infants (49%)

The SickKids NICU …

Canadian Neonatal Network

Enables and promotes evidence-based intensive care in NICUs within Canada

Variation in practice and outcomes

Unique opportunity for researchers to participate in collaborative projects

Clinical, epidemiological, outcomes, and health services research aimed at improving both the efficacy and efficiency of neonatal care

Outline for the presentation . . .

Brief history of neonatal resuscitation

Evolution of NRP in Canada

NRP at SickKids

Research

Perinatal physiology

A clinical approach . . .

Concluding remarks

A brief history . . .

Long history of attempts to “revive” newborn infants using . . .

Objective assessment of the state of the newborn infant at birth . . .

Intervention with intubation, ventilation, external cardiac massage, volume expansion, sodium bicarbonate, and other drugs . . .

Recognition of “transition” form one environment to another . . . move toward “gentle’ resuscitation

Evolution of NRP in Canada . . .

1980’s No formal structure, hospital-based programmes

1990’s Informal structure within the provinces

Involvement of members of Canadian Paediatric Society

Affiliation with provincial Heart and Stroke Foundation of Ontario

2000’s Involvement of Canadian Paediatric Society

Active promotion, educational programmes, resources for providers and instructors

Governance in Canada. . .

Executive Committee (8 members)

NRP Steering Committee (Executive plus provincial and

professional liaisons)

Subcommittees

• Education

• Resuscitation science

Resuscitation science . . .

NRP grant competition

First competition in 2009 – doubling of submissions in last competition

NRP Resuscitation Club First meeting in 2008 Hot topics, research presentations, debatesFeedback has been overwhelming positive, only forum of this nature anywhere in the world

• 2009 — development of team competencies

• 2010 — effectiveness of tean debriefing

Research . . .

Paucity of research . . .

Animal research . . . low vs high dose epinephrine, ADH (McNamara et al, 2007)

Simulation . . . Low fidelity vs high fidelity (Finar et al, 2009)

• extrapolation from other populations• reliance upon expert opinion

NRP in Canada . . .

Neonatal Resuscitation Programmehttp://www.cps.ca/English/ProEdu/NRP/Index.htm

Recommendations for specific treatment modifications in the Canadian contexthttp://www.cps.ca/English/ProEdu/NRP/addendum.pdf

A brief summary for busy physicians . . . http://www.cps.ca/English/ProEdu/NRP/NRP_Revisions.pdf

NRP 2006 Flow Diagram - Canadian Adaptationhttp://www.cps.ca/English/ProEdu/NRP/Flow_diagram.pdf

NRP at SickKids . . .

• Train the instructors (8 hour programme)• Audit the instructors to ensure consistency• Update for instructors whenever changes or every

four years• Physician certification; recertification every 2 years• Nursing staff: 8 hour programme during orientation• Recertification classes every month (4 hours)• Low fidelity megacodes• Educational resources available within NICU

Active educational programme within the NICU, external support from The Mitchener Institute

Delivery room care of the neonate

Primary goal is to support the newborn’s respiratory and cardiovascular functions during the transition from fetal to neonatal life

Normal physiological changes at birth include:

• Expansion of the lungs• Initial of gas exchange• Rapid increase in pulmonary blood flow• Absorption of fetal lung fluid• Transition to neonatal circulation: decrease in

PVR, closure of fetal shunts• Metabolic and endocrine changes

An approach to resuscitation . . .

1. Expand the lungs and maintain adequate ventilation and oxygenation

2. Maintain adequate cardiac output and tissue perfusion

3. Maintain normal core temperature and avoid hypoglycaemia while stabilising the baby for transfer to the nursery

Basic goals of neonatal resuscitation are to:

The fundamentals . . .

A Anticipation

Assessment

Airway

B Breathing

C Circulation

D Diagnosis

Definitive treatment

Drugs

E Energy metabolism

Evaluation

Perinatal physiology . . .

The first breath

Pressure volume loops

Changes in the pulmonary circulation

Perinatal acid-base status

Perinatal circulation

The first breath . . .

Pressure volume loops . . .

Pulmonary circulation . . .

Perinatal acid-base status . . .

Perinatal circulation . . .

Airway Is the airway patent?

Breathing Is the baby breathing normally?

Circulation Is the circulation normal?

A B C . . . the fundamentals . . .

The airway . . .

Is the airway patent?

Is the airway patent after repositioning the baby?

is the airway patent after suctioning?

Does the baby have a congenital abnormality of the airway?

Breathing . . .

Is the baby breathing adequately?

Does the baby have respiratory distress?

Is the chest shape normal and symmetrical?

Is air entry normal and symmetrical?

Where is the apex beat?

Circulation . . .

What is the heart rate?

Is the perfusion normal?

Are the peripheral pulses normal?

Does the baby have a murmur?

Are the heart sounds normal?

D E F . . . the extras . . .

Drugs What is the diagnosis?

What is the definitive treatment for this baby?

Does this baby require drugs?

Evaluation Is this baby improving?

Finish Should resuscitation be discontinued?

Perinatal asphyxia . . .

Asphyxia is the consequence of inadequate cellular oxygenation and is associated with tissue hypoxia, anaerobic metabolism and acidosis.

After delivery, ineffective respiratory efforts and decreased cardiac output will result in progressive biochemical changes

• plasma pO2 zero in less than 5 minutes• increase pCO2 of 7-8 mmHg/min• decrease pH of 0.04 units/min• decrease in HCO3 of 2 mmol/min

Therapeutic hypothermia . . .

Gestational age ≥ 35 weeksModerate or severe encephalopathyEvidence of intrapartum hypoxia (2 or more of the following criteria)

• Apgar score > 6 at 10 minutes• Need for resuscitation or mechanical ventilation

beyond 10 minutes of age• EITHER cord or blood gas within one hour of birth

with pH < 7.00, • OR cord or arterial gas within one hour of birth with

base deficit > 16

Concluding remarks . . .

Organisational support within countries . . .

Structured, team approach to neonatal resuscitation

Educational programmes and resources

Formal certification process

Many unanswered questions . . . research