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Update

Indian Pediatr 2016;53:1091-1092

What is New in the 2015 PALS Update?


Shalu Gupta and Muralidharan Jayashree

From Department of Pediatrics, Advanced Pediatrics Centre, PGIMER, Chandigarh, India.

Correspondence to: Dr. Shalu Gupta, DM Critical Care Fellow, Pediatric Emergency and Intensive Care, Advanced Pediatrics Centre, PGIMER, Chandigarh, India.
Email: [email protected]



T
he past decade has seen a marked improvement in the survival to discharge rates from pediatric in-hospital cardiac arrest (IHCA). Rates of return of spontaneous circulation (ROSC) from IHCA has increased significantly from 39% to 77%, and survival to hospital discharge improved from 24% to 36- 43%, for the period from 2001 to 2013 [1]. However, the same survival benefit has not been reported for out-of-hospital cardiac arrest (OHCA); 8.3% survival to hospital- discharge across all age-groups [2].

The American Heart Association (AHA) Guidelines for CPR and ECC for Pediatric Advanced Life Support (PALS) are updated every 5 years based on the body of evidence that has accumulated over this period. The current update (2015) to the 2010 AHA Guidelines focuses on certain key areas related to pediatric resuscitation [3,4].

The questions to be addressed in PICO format (population, intervention, comparator, and outcome) were identified and prioritized by seven task forces. These questions pertained to three core areas viz, pre-arrest, intra-arrest, and post-resuscitation care. The patient outcomes studied were short term i.e., beyond ROSC or discharge from the pediatric intensive care unit (PICU) and long term survival with favorable neurologic/functional status at 30, 60 and 180 days, and 1 year.

A detailed search for relevant articles was performed in all the three online databases (PubMed, Embase, and the Cochrane Library) following which each task force carried out a detailed systematic review based on the recommendations of the Institute of Medicine of the National Academies [5].

Each recommendation is labeled with a Class of Recommendation (COR) and a Level of Evidence (LOE).The quality of the evidence was categorized into high, moderate, low, or very low, based on the study methodologies and the five core GRADE domains of risk of bias, inconsistency, indirectness, imprecision, and publication bias [6]. This update used the most recent AHA COR and LOE classification system that is a modification of the Class III recommendation and introduces LOE B-R (randomized studies) and B-NR (non-randomized studies) as well as LOE C-LD (limited data) and LOE C-EO (consensus of expert opinion) [3]. Based on the above, the task force then formulated 18 questions in the following areas and critically appraised the available evidence. The same is summarized in the accompanying tables (Web Tables I-III).

A. Pediatric Pre-arrest Care: In pre-arrest scenario, the following five areas were considered important so as to prevent a cardiac or respiratory arrest (WebTable I).

1. Rapid response team (RRT)/Medical Emergency team (MET).

2. Pediatric Early Warning Score (PEWS).

3. Specific management in dilated cardiomyopathy (DCMP)/Mycarditis.

4. Use of atropine as premedication.

5. Use of restrictive volumes and non-crystalloids in septic shock.

B. Intra-arrest– Advanced Life Support: Seven aspects during advanced life support delivery were looked at to improve outcomes (Web Table II).

1. Energy dose for initial and subsequent defibrillation.

2. Use of invasive hemodynamic monitoring for systolic and diastolic BP titration.

3. Chest compression techniques to achieve a specific ETCO2 threshold.

4. Use of amiodarone for shock-refractory VF or pulseless VT (pVT).

5. Use of vasopressor/s during cardiac arrest e.g. epinephrine/vasopressin.

6. Use of ECMO for resuscitation (ECPR).

7. Significance of any intra-arrest prognostic factors.

C. Post arrest care: Six key areas in post arrest management were reviewed to give recommendations (WebTable III).

1. Role of targeted temperature management (TTM).

2. Use of targeted PaO2.

3. Ventilation to targeted PCO2.

4. Targeted perfusion and BP with fluids, inotropes and/or vasopressors.

5. Use of EEG.

6. Role of any prognostic factors.

Contributors: SG: drafted the manuscript; MJ: editing, critical revision, and final approval.

Funding: None; Competing interest: None stated.

References

1. Girotra S, Spertus JA, Li Y, Berg RA, Nadkarni VM, Chan PS, et al. American Heart Association Get With The Guidelines – Resuscitation Investigators. Survival trends in pediatric in-hospital cardiac arrests: an analysis from Get with the Guidelines – Resuscitation. Circ Cardiovasc Qual Outcomes. 2013; 6:42-49.

2. Sutton RM, Case E, Brown SP, Atkins DL, Nadkarni VM, Kaltman J, et al. A quantitative analysis of out-of –hospital pediatric and adolescent resuscitation quality. A report from the ROC Epistry – Cardiac arrest. Resuscitation. 2015; 93:150-157.

3. De Caen AR, Berg MD, Chameides L, Gooden Ck, Hickey RW, Scott HF, et al. Part 12: Pediatric Advanced Life Support: 2015 American Heart Association Guidelines Update for Cardiopulmonary Resuscitation and Emergency Cardiovascular Care. Circulation. 2015; 132(suppl): S526-42.

4. Maconochie IK, De Caen AR, Aickin R, Atkins DL, Biarent D, Guerguerian AM, et al. on behalf of the Pediatric Basic Life Support and Pediatric Advanced Life Support Chapter Collaborators. Part 6: Pediatric Basic Life Support and Pediatric Advanced Life Support 2015 International Consensus on Cardiopulmonary Resusci-tation and Emergency Cardiovascular Care Science with Treatment Recommendations. Resuscitation. 2015; 95: e147-68.

5. Institute of Medicine. Standards for Systematic Reviews. 2011. Available from: http:// www.iom.edu/Reports/2011/Finding-What-Works-in-Health-Care-Standards-for-Systematic-Reviews/Standards.aspx. Accessed August 15, 2015.

6. Schünemann HJ, Schünemann AH, Oxman AD, Brozek J, Glasziou P, Jaeschke R, et al. GRADE Working Group. Grading quality of evidence and strength of recommen-dations for diagnostic tests and strategies. BMJ. 2008; 336:1106-10.

7. Ngo NT, Cao XT, Kneen R, Wills B, Nguyen VM, Nguyen TQ, et al. Acute management of dengue shock syndrome: a randomized double-blind comparison of 4 intravenous fluid regimens in the first hour. Clin Infect Dis. 2001; 32:204-13.

8. Jacobs IG, Finn JC, Jelinek GA, Oxer HF, Thompson PL. Effect of adrenaline on survival in out-of-hospital cardiac arrest: a randomized double-blind placebo-controlled trial. Resuscitation. 2011;82:1138-43.

9. Kitamura T, Iwami T, Kawamura T, Nagao K, Tanaka H, Nadkarni VM, et al. Conventional and chest-compression-only cardiopulmonary resuscitation by bystanders for children who have out-of-hospital cardiac arrests: a prospective, nationwide, population-based cohort study. Lancet. 2010; 375:1347-54.

10. Lin JJ, Hsia SH, Wang HS, Chiang MC, Lin KL. Therapeutic hypothermia associated with increased survival after resuscitation in children. Pediatr Neurol. 2013; 4:285-90.

11. Castillo DJ, López-Herce J, Matamoros M, Cańadas S, Rodriguez- Calvo A, Cechetti C, et al. Iberoamerican Pediatric Cardiac Arrest Study Network RIBEPCI. Hyperoxia, hypocapnia and hypercapnia as outcome factors after cardiac arrest in children. Resuscitation. 2012; 83:1456-61.

 

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