Part 12: Pediatric Advanced Life Support

Reprint: The American Heart Association requests that this document be cited as follows: de Caen AR, Berg MD, Chameides L, Gooden CK, Hickey RW, Scott HF, Sutton RM, Tijssen JA, Topjian A, van der Jagt E, Schexnayder SM, Samson RA. Part 12: pediatric advanced life support: 2015 American Heart Association Guidelines Update for Cardiopulmonary Resuscitation and Emergency Cardiovascular Care. Circulation. 2015;132(suppl 2):S526–S542.Reprinted with permission of the American Heart Association, Inc. This article has been published in Circulation.Over the past 13 years, survival to discharge from pediatric in-hospital cardiac arrest (IHCA) has markedly improved. From 2001 to 2013, rates of return of spontaneous circulation (ROSC) from IHCA increased significantly from 39% to 77%, and survival to hospital discharge improved from 24% to 36% to 43% (Girotra et al1 and personal communication with Paul Chan, MD, MSc, April 3, 2015). In a single center, implementation of an intensive care unit (ICU)–based interdisciplinary debriefing program improved survival with favorable neurologic outcome from 29% to 50%.2 Furthermore, new data show that prolonged cardiopulmonary resuscitation (CPR) is not futile: 12% of patients receiving CPR in IHCA for more than 35 minutes survived to discharge, and 60% of the survivors had a favorable neurologic outcome.3 This improvement in survival rate from IHCA can be attributed to multiple factors, including emphasis on high-quality CPR and advances in post-resuscitation care. Over the past decade, the percent of cardiac arrests occurring in an ICU setting has increased (87% to 91% in 2000 to 2003 to 94% to 96% in 2004 to 2010).4 While rates of survival from pulseless electrical activity and asystole have increased, there has been no change in survival rates from in-hospital ventricular fibrillation (VF) or pulseless ventricular tachycardia (pVT).Conversely, survival from out-of-hospital cardiac arrest (OHCA) has not improved as dramatically over the past 5 years. Data from 11 US and Canadian hospital emergency medical service systems (the Resuscitation Outcomes Consortium) during 2005 to 2007 showed age-dependent discharge survival rates of 3.3% for infants (less than 1 year), 9.1% for children (1 to 11 years), and 8.9% for adolescents (12 to 19 years).5 More recently published data (through 2012) from this network demonstrate 8.3% survival to hospital discharge across all age groups, with 10.5% survival for children aged 1 to 11 years and 15.8% survival for adolescents aged 12 to 18 years.6The American Heart Association (AHA) Emergency Cardiovascular Care (ECC) Committee uses a rigorous process to review and analyze the peer-reviewed published scientific evidence supporting the AHA Guidelines for CPR and ECC, including this update. In 2000, the AHA began collaborating with other resuscitation councils throughout the world, via the International Liaison Committee on Resuscitation (ILCOR), in a formal international process to evaluate resuscitation science. This process resulted in the publication of the International Consensus on CPR and ECC Science With Treatment Recommendations (CoSTR) in 2005 and 2010.7,8 These publications provided the scientific support for AHA Guidelines revisions in those years.In 2011, the AHA created an online evidence review process, the Scientific Evidence Evaluation and Review System (SEERS), to support ILCOR systematic reviews for 2015 and beyond. This new process includes the use of Grading of Recommendations Assessment, Development, and Evaluation (GRADE) software to create systematic reviews that will be available online and used by resuscitation councils to develop their guidelines for CPR and ECC. The drafts of the online reviews were posted for public comment, and ongoing reviews will be accessible to the public (https://volunteer.heart.org/apps/pico/Pages/default.aspx).The AHA process for identification and management of potential conflicts of interest was used, and potential conflicts for writing group members are listed at the end of each Part of the 2015 AHA Guidelines Update for CPR and ECC. For additional information about this systematic review or management of the potential conflicts of interest, see “Part 2: Evidence Evaluation and Management of Conflicts of Interest” in this supplement and the related article “Part 2: Evidence Evaluation and Management of Conflict of Interest” in the 2015 CoSTR publication.9,10This update to the 2010 AHA Guidelines for CPR and ECC for pediatric advanced life support (PALS) targets key questions related to pediatric resuscitation. Areas of update were selected by a group of international pediatric resuscitation experts from ILCOR, and the questions encompass resuscitation topics in prearrest care, intra-arrest care, and postresuscitation care. The ILCOR Pediatric Life Support Task Force experts reviewed the topics addressed in the 2010 Guidelines for PALS and, based on in-depth knowledge of new research developments, formulated 18 questions for further systematic evaluation.11 Three questions that address pediatric basic life support appear in “Part 11: Pediatric Basic Life Support and Cardiopulmonary Resuscitation Quality.”Beginning with the publication of the 2015 CoSTR, the ILCOR evidence evaluation process will be continuous, rather than “batched” into 5-year cycles. The goal of this continuous evidence review is to improve survival from cardiac arrest by shortening the time between resuscitation science discoveries and their application in resuscitation practice. As additional resuscitation topics are prioritized and reviewed, these Guidelines may be updated again. When the evidence supports sufficient changes to the Guidelines or a change in sequence or treatments that must be woven throughout the Guidelines, then the Guidelines will be revised completely.Because the 2015 AHA Guidelines Update for CPR and ECC represents the first update to the previous Guidelines, recommendations from both this 2015 Guidelines Update and the 2010 Guidelines are contained in the Appendix. If the 2015 ILCOR review resulted in a new or significantly revised Guidelines recommendation, that recommendation will be labeled as New or Updated.As with all AHA Guidelines, each 2015 recommendation is labeled with a Class of Recommendation (COR) and a Level of Evidence (LOE). This update uses the newest AHA COR and LOE classification system, which contains modifications of the Class III recommendation and introduces LOE B-R (randomized studies) and B-NR (nonrandomized studies) as well as LOE C-LD (limited data) and LOE C-EO (consensus of expert opinion).These PALS recommendations are informed by the rigorous systematic review and consensus recommendations of the ILCOR Pediatric Task Force, and readers are referred to the complete consensus document in the 2015 CoSTR.12,13 In the online version of this document, live links are provided so the reader can connect directly to the systematic reviews on the SEERS website. These links are indicated by a superscript combination of letters and numbers (eg, Peds 397). We encourage readers to use the links and review the evidence and appendixes, including the GRADE tables.This 2015 Guidelines Update for PALS includes science review in the following subjects:Prearrest CareIntra-arrest CarePostarrest CareMedical emergency team or rapid response team activation by caregivers or parents ideally occurs as a response to changes noted in a patient’s condition and may prevent cardiac or respiratory arrest. Several variables, including the composition of the team, the type of patient, the hospital setting, and the confounder of a wider “system benefit,” further complicate objective analyses.Observational data have been contradictory and have not consistently shown a decreased incidence of cardiac and/or respiratory arrest outside of the ICU setting.14–16 The data addressing effects on hospital mortality were inconclusive.16–21Pediatric medical emergency team/rapid response team systems may be considered in facilities where children with high-risk illnesses are cared for on general in-patient units (Class IIb, LOE C-LD).In-hospital pediatric cardiac or respiratory arrest can potentially be averted by early recognition of and intervention for the deteriorating patient. The use of scoring systems might help to identify such patients sufficiently early so as to enable effective intervention.There is no evidence that the use of PEWS outside of the pediatric ICU setting reduces hospital mortality. In 1 observational study, PEWS use was associated with a reduction in cardiac arrest rate when used in a single hospital with an established medical emergency team system.22The use of PEWS may be considered, but its effectiveness in the in-hospital setting is not well established (Class IIb, LOE C-LD).This update regarding intravenous fluid resuscitation in infants and children in septic shock in all settings addressed 2 specific therapeutic elements: (1) Withholding the use of bolus fluids was compared with the use of bolus fluids, and (2) noncrystalloid was compared with crystalloid fluids.Early and rapid administration of intravenous fluid to reverse decompensated shock, and to prevent progression from compensated to decompensated shock, has been widely accepted based on limited observational studies.23 Mortality from pediatric sepsis has declined in recent years, during which guidelines and publications have emphasized the role of early rapid fluid administration (along with early antibiotic and vasopressor therapy, and careful cardiovascular monitoring) in treating septic shock.24,25 Since the 2010 Guidelines, a large randomized controlled trial of fluid resuscitation in pediatric severe febrile illness in a resource-limited setting found intravenous fluid boluses to be harmful.26 This new information, contradicting long-held beliefs and practices, prompted careful analysis of the effect of fluid resuscitation on many outcomes in specific infectious illnesses.Specific infection-related shock states appear to behave differently with respect to fluid bolus therapy. Evidence was not considered to be specific to a particular setting, after determining that “resource-limited setting” is difficult to define and can vary greatly even within individual health systems and small geographic regions.The evidence regarding the impact of restricting fluid boluses during resuscitation on outcomes in pediatric septic shock is summarized in Figure 1. There were no studies for many specific combinations of presenting illness and outcome. In the majority of scenarios, there was no benefit to restricting fluid boluses during resuscitation.The most important exception is that in 1 large study, restriction of fluid boluses conveyed a benefit for survival to both 48 hours and 4 weeks after presentation. This study was conducted in sub-Saharan Africa, and inclusion criteria were severe febrile illness complicated by impaired consciousness (prostration or coma), respiratory distress (increased work of breathing), or both, and with impaired perfusion, as evidenced by 1 or more of the following: a capillary refill time of 3 or more seconds, lower limb temperature gradient, weak radial-pulse volume, or severe tachycardia. In this study, administration of 20 mL/kg or 40 mL/kg in the first hour was associated with decreased survival compared with the use of maintenance fluids alone.26 Therefore, it appears that in this specific patient population, where critical care resources including inotropic and mechanical ventilator support were limited, bolus fluid therapy resulted in higher mortality.The use of noncrystalloid fluid was compared with crystalloid fluid for the same diseases and outcomes listed in the preceding paragraph.26–32 Evidence is summarized in Figure 2. In most scenarios, there was no benefit to noncrystalloids over crystalloids. In patients with Dengue shock, a benefit was conferred in using noncrystalloid compared with crystalloid fluid for the outcome of time to resolution of shock.31Administration of an initial fluid bolus of 20 mL/kg to infants and children with shock is reasonable, including those with conditions such as severe sepsis (Class IIa, LOE C-LD), severe malaria and Dengue (Class IIb, LOE B-R). When caring for children with severe febrile illness (such as those included in the FEAST trial26) in settings with limited access to critical care resources (ie, mechanical ventilation and inotropic support), administration of bolus intravenous fluids should be undertaken with extreme caution because it may be harmful (Class IIb, LOE B-R). Providers should reassess the patient after every fluid bolus (Class I, LOE C-EO).Either isotonic crystalloids or colloids can be effective as the initial fluid choice for resuscitation (Class IIa, LOE B-R).This recommendation takes into consideration the important work of Maitland et al,26 which found that fluid boluses as part of resuscitation are not safe for all patients in all settings. This study showed that the use of fluid boluses as part of resuscitation increased mortality in a specific population in a resource-limited setting, without access to some critical care interventions such as mechanical ventilation and inotrope support.The spirit of this recommendation is a continued emphasis on fluid resuscitation for both compensated (detected by physical examination) and decompensated (hypotensive) septic shock. Moreover, emphasis is also placed on the use of individualized patient evaluation before the administration of intravenous fluid boluses, including physical examination by a clinician and frequent reassessment to determine the appropriate volume of fluid resuscitation. The clinician should also integrate clinical signs with patient and locality-specific information about prevalent diseases, vulnerabilities (such as severe anemia and malnutrition), and available critical care resources.Bradycardia commonly occurs during emergency pediatric intubation, resulting from hypoxia/ischemia, as a vagal response to laryngoscopy, as a reflex response to positive pressure ventilation, or as a pharmacologic effect of some drugs (eg, succinylcholine or fentanyl). Practitioners have often tried to blunt this bradycardia with prophylactic with evidence regarding the use of during emergency has been including from with in the More recent in-hospital of and children emergency is no evidence that use of survival or cardiac arrest in infants and data that it the of survival to ICU discharge in children than Evidence is as to administration reduces the incidence of or past Guidelines, a of was after a of bradycardia in small infants in 2 of the most recent cited of with no were shown to be available evidence not support the use of of infants and may be for to use as a in specific emergency when there is higher of bradycardia (eg, when succinylcholine as a to (Class IIb, LOE of of with no may be considered when is used as a for emergency (Class IIb, LOE This new recommendation to the use of as a for infants and children during emergency care of a or with or should cardiac arrest. While with the care of these the evidence is The ILCOR systematic review its analysis to patients with and not the use of ventricular was prearrest management for infants and children with or observational data support the arrest use of in children with use may be considered in patients with are at of cardiac arrest (Class IIb, LOE outcomes from are in settings with and 2010 AHA PALS Guidelines the use of when with pediatric cardiac arrest to interventions and when a Pediatric was not considered for the 2015 ILCOR systematic from 4 observational studies of pediatric IHCA has shown no benefit to the use of CPR with compared to CPR without data from a of pediatric IHCA showed improved survival to hospital discharge with the use of in patients with cardiac For children with cardiac when is in a critical care setting, survival has been even after more than minutes of When is used during cardiac the outcome for children with cardiac is than for those with may be considered for pediatric patients with cardiac have IHCA in settings with and (Class IIb, LOE CPR is associated with improved outcomes after cardiac arrest. data support a between and cardiac is used during pediatric cardiac arrest to for as well as CPR The 2010 Guidelines that the pressure of is consistently than should on CPR and that the not is no pediatric evidence that outcomes from cardiac arrest. pediatric study showed that are as effective as by and for recent study in found that during CPR were significantly associated with and ventilation may be considered to evaluate the of but specific to therapy have not been established in children (Class IIb, LOE and during pediatric cardiac arrest of CPR in patients where CPR is continued CPR in patients with a potential for infants and children with age than 1 of cardiac and with a as to a are all of patient outcome. For infants and children with age than 1 and of cardiac The evidence is contradictory as to a to initial cardiac arrest is a in the in-hospital should be used when to outcomes during cardiac arrest (Class I, LOE there are associated with or no single outcome with sufficient to or of often have cardiac arrests in settings where or is If a patient has an the can be used as to evaluate to a specific pressure has not been in randomized controlled studies showed increased of and survival to of with the use of patients with in at the time of cardiac it may be for to use pressure to CPR (Class IIb, LOE for pressure during CPR have not been established in cardiac are used to spontaneous circulation by and to help also and which might be are no pediatric studies that demonstrate the effectiveness of or combination of in cardiac arrest. pediatric observational out-of-hospital had many to determine were randomized controlled showed use was associated with increased and survival to hospital but no improvement in survival to hospital is to in pediatric cardiac arrest (Class IIa, LOE 2005 and 2010 Guidelines in to for the management of or This recommendation was based on pediatric or from studies that used pediatric observational showed improved with the use of as compared with of compared with no was significantly associated with an increased of The same study not show an between or use and survival to hospital or or may be used (Class IIb, LOE Pediatric this 2015 ILCOR systematic review addressed the of for pediatric during cardiac arrest. the related to the for was in this evidence small of with 2 or 2 to 4 In 1 observational study of a higher initial of more than 3 to 5 was effective than 1 to 3 in small observational study of showed no benefit in with a specific for initial Three small observational studies of IHCA and showed no survival to discharge of compared with 2 to 4 for initial is to use an initial of 2 to 4 of or for (Class IIa, LOE C-LD), but for of an initial of 2 may be considered (Class IIb, LOE For it is to the to 4 (Class IIa, LOE For a of 4 may be and higher may be considered, not to or the (Class IIb, LOE that after pediatric cardiac arrest is and is associated with The 2010 AHA PALS Guidelines a role for temperature management after pediatric cardiac arrest for all therapeutic for some but the recommendations were based on from and large randomized study of pediatric patients 2 to 18 with found no in survival with outcome at 1 and no additional in patients were with therapeutic to compared to those with to data of pediatric patients from IHCA or have also shown that ICU of neurologic and mortality are with the use of therapeutic 1 small study of therapeutic in survivors of pediatric cardiac showed an improvement in mortality at hospital discharge, but with no in neurologic are from a large randomized controlled trial of temperature management for pediatric patients with IHCA infants and children after it is to 5 of continuous to or to 2 of initial continuous to by 3 of continuous (Class IIa, LOE B-R). of temperature during this time is (Class I, LOE infants and children after there is evidence to over or should be after (Class I, LOE studies that of after to that may the postresuscitation some studies show between and increased small observational studies of pediatric IHCA and not show an between and outcome. In a observational study of pediatric IHCA and survived to pediatric ICU after of the of as a or and than when compared with than after was associated with improved survival to pediatric ICU may be for to after (Class IIb, LOE an of may to a between and it may be the is to to an of than but 94% or The goal of such an is to that is is to a appropriate to the specific patient may be after data show an between and patient In other of pediatric is associated with clinical were no studies in children after cardiac arrest ventilation with a small observational study of both pediatric IHCA and no between than or than and outcome. in an observational study of pediatric or was associated with survival to hospital is for to a after that is appropriate to the specific patient and to severe or (Class IIb, LOE and are after resuscitation from cardiac small observational studies pediatric IHCA and survival to hospital discharge when children were to of these associated as a pressure than for after IHCA with lower of survival to discharge with favorable neurologic outcome. There are no studies the benefit of specific after in infants and that fluids and/or or drugs be used to a pressure than for age (Class I, LOE When appropriate resources are continuous pressure is to identify and (Class I, LOE and of neurologic outcome in pediatric survivors of cardiac arrest is to enable effective and support it be to or data from 2 small pediatric showed that a continuous and on an in the first after cardiac arrest was associated with a significantly higher of neurologic outcome at hospital discharge, an a or was associated with a neurologic outcome at hospital There are no data with neurologic outcome after hospital within the first after pediatric cardiac arrest may be considered in neurologic outcome at the time of hospital discharge (Class IIb, LOE but should not be used as the have been as of survival and neurologic outcome after pediatric cardiac arrest. These the of neurologic and observational studies the use of at 12 to hours after cardiac arrest in survival to 1 observational study found that hours after cardiac arrest were associated with improved survival at with favorable neurologic of neurologic have been considered for their small observational studies found that lower and after arrest were associated with improved survival to hospital discharge and with improved survival with favorable neurologic observational study found that children with lower in the first 12 hours after arrest had an improved survival to hospital of 1 for in children after cardiac arrest has not been Practitioners should multiple when outcomes in infants and children after cardiac arrest (Class I, LOE