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

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

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

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?

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