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 ETCO
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.