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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•2009 – development of team competencies•2010 – effectiveness of team debriefing
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
Research . . .
Paucity of research . . .
•extrapolation from other populations
•reliance upon expert opinion
Animal research . . . low vs high dose epinephrine, ADH (McNamara et al, 2007)
Simulation . . . Low fidelity vs high fidelity (Finar et al, 2009)
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 . . .
Active educational programme within the NICU, external support from The Mitchener Institute•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
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 . . .
Basic goals of neonatal resuscitation are to:
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
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 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
Concluding remarks . . .
Organisational support within countries . . .
Structured, team approach to neonatal resuscitation
Educational programmes and resources
Formal certification process
Many unanswered questions . . . research