This document summarizes a presentation on neonatal resuscitation in Canada. It provides background on the neonatal intensive care unit at SickKids hospital, the evolution of the Neonatal Resuscitation Program in Canada, and research in resuscitation science. It also outlines the fundamentals of neonatal resuscitation, including assessing the airway, breathing and circulation, and covers perinatal physiology topics like the first breath and pulmonary circulation.

1. Neonatal Resuscitation A Canadian Perspective Andrew James MBChB MBI FRACP FRCPC Associate Clinical Director, NICU The Hospital for Sick Children, Toronto Associate Professor, Department of Paediatrics University of Toronto, Toronto, ON, Canada Fourth Annual NRP Conference, Shenzhen, China, October 19-22, 2010

2. Neonatal intensive care unit

3. Advanced multidisciplinary practice

4. 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

5. The SickKids NICU … Full term infants (51%) Preterm infants (49%)

6. 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

7. 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

8. 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

9. 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

10. Governance in Canada. . . Executive Committee (8 members) NRP Steering Committee (Executive plus provincial and professional liaisons) Subcommittees Education Resuscitation science

11. 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, debates Feedback has been overwhelming positive, only forum of this nature anywhere in the world 2009 — development of team competencies 2010 — effectiveness of tean debriefing

12. 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

13. NRP in Canada . . . Neonatal Resuscitation Programme http://www.cps.ca/English/ProEdu/NRP/Index.htm Recommendations for specific treatment modifications in the Canadian context http://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 Adaptation http://www.cps.ca/English/ProEdu/NRP/Flow_diagram.pdf

15. 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

16. 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

17. An approach to resuscitation . . . Expand the lungs and maintain adequate ventilation and oxygenation Maintain adequate cardiac output and tissue perfusion Maintain normal core temperature and avoid hypoglycaemia while stabilising the baby for transfer to the nursery Basic goals of neonatal resuscitation are to:

18. The fundamentals . . . A Anticipation Assessment Airway B Breathing C Circulation D Diagnosis Definitive treatment Drugs E Energy metabolism Evaluation

19. Perinatal physiology . . . The first breath Pressure volume loops Changes in the pulmonary circulation Perinatal acid-base status Perinatal circulation

20. The first breath . . .

21. Pressure volume loops . . .

22. Pulmonary circulation . . .

23. Perinatal acid-base status . . .

24. Perinatal circulation . . .

25. Airway Is the airway patent? Breathing Is the baby breathing normally? Circulation Is the circulation normal? A B C . . . the fundamentals . . .

26. 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?

27. 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?

28. 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?

29. 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?

30. 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

31. Therapeutic hypothermia . . . Gestational age ≥ 35 weeks Moderate or severe encephalopathy Evidence 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

32. Concluding remarks . . . Organisational support within countries . . . Structured, team approach to neonatal resuscitation Educational programmes and resources Formal certification process Many unanswered questions . . . research