Part 6: Pediatric basic life support and pediatric advanced life support: 2015 International Consensus on Cardiopulmonary Resuscitation and Emergency Cardiovascular Care Science with Treatment Recommendations☆,☆☆
Introduction
The Pediatric Task Force reviewed all questions submitted by the International Liaison Committee on Resuscitation (ILCOR) member councils in 2010, reviewed all council training materials and resuscitation guidelines and algorithms, and conferred on recent areas of interest and controversy. We identified a few areas where there were key differences in council-specific guidelines based on historical recommendations, such as the A–B–C (Airway, Breathing, Circulation) versus C–A–B (Circulation, Airway, Breathing) sequence of provision of cardiopulmonary resuscitation (CPR), initial back blows versus abdominal thrusts for foreign-body airway obstruction, an upper limit for recommended chest compression rate, and initial defibrillation dose for shockable rhythms (2 versus 4 J kg−1). We produced a working list of prioritized questions and topics, which was adjusted with the advent of new research evidence. This led to a prioritized palate of 21 PICO (population, intervention, comparator, outcome) questions for ILCOR task force focus.
The 2015 process was supported by information specialists who performed in-depth systematic searches, liaising with pediatric content experts so that the most appropriate terms and outcomes and the most relevant publications were identified. Relevant adult literature was considered (extrapolated) in those PICO questions that overlapped with other task forces, or when there were insufficient pediatric data. In rare circumstances (in the absence of sufficient human data), appropriate animal studies were incorporated into reviews of the literature. However, these data were considered only when higher levels of evidence were not available and the topic was deemed critical.
When formulating the PICO questions, the task force felt it important to evaluate patient outcomes that extend beyond return of spontaneous circulation (ROSC) or discharge from the pediatric intensive care unit (PICU). In recognition that the measures must have meaning, not only to clinicians but also to parents and caregivers, longer-term outcomes at 30 days, 60 days, 180 days, and 1 year with favorable neurologic status were included in the relevant PICO questions.
Each task force performed a detailed systematic review based on the recommendations of the Institute of Medicine of the National Academies1 and using the methodological approach proposed by the Grading of Recommendations, Assessment, Development, and Evaluation (GRADE) working group.2 After identifying and prioritizing the questions to be addressed (by using the PICO format)3 with the assistance of information specialists, a detailed search for relevant articles was performed in each of three online databases (PubMed, Embase, and the Cochrane Library).
By using detailed inclusion and exclusion criteria, articles were screened for further evaluation. The reviewers for each question created a reconciled risk-of-bias assessment for each of the included studies, using state-of-the-art tools: Cochrane for randomized controlled trials (RCTs),4 Quality Assessment of Diagnostic Accuracy Studies (QUADAS)-2 for studies of diagnostic accuracy,5 and GRADE for observational studies that inform both therapy and prognosis questions.6
GRADE evidence profile Tables 7 were then created to facilitate an evaluation of the evidence in support of each of the critical and important outcomes. The quality of the evidence (or confidence in the estimate of the effect) was categorized as high, moderate, low, or very low,8 based on the study methodologies and the five core GRADE domains of risk of bias, inconsistency, indirectness, imprecision, and other considerations (including publication bias).9
These evidence profile tables were then used to create a written summary of evidence for each outcome (the consensus on science statements). Whenever possible, consensus-based treatment recommendations were then created. These recommendations (designated as strong or weak) were accompanied by an overall assessment of the evidence and a statement from the task force about the values and preferences that underlie the recommendations.
Further details of the methodology that underpinned the evidence evaluation process are found in “Part 2: Evidence evaluation and management of conflicts of interest.”
The pediatric task force included several authors who had produced some of the most important primary work found in the literature. To ensure that there was transparency, and that there was not undue bias, the task force sought opinions as a whole with the interests of the involved author declared at the outset. At face-to-face meetings, this allowed for examination in detail of those papers, producing better understanding of the limitations and interpretation of the work of those authors. Consistent with the policies to manage potential conflicts of interest, participants in discussions with any potential conflicts abstained from any voting on the wording of the consensus on science or treatment recommendations.
External content experts attended the face-to-face meeting in February 2015 in Dallas (ILCOR 2015 International Consensus Conference on CPR and Emergency Cardiovascular Care Science With Treatment Recommendations), providing further independent review beyond that achieved by public consultation. This conference included representation from the World Health Organization (WHO) to add perspective on the global application of the guidelines. These collaborations enhanced participants’ understanding of the variability of health care in resource-replete settings, with the realization that the “developed world” has certain parallels to resource-deplete settings. It was clearly understood that the economic classifications of “low-,” “middle-,” or “high-income country” are inadequate to explain the range of health care available within each country and that the information derived as part of any review of the scientific literature had to be viewed in context of the resources available to appropriately shape local guidelines. The WHO also uses the GRADE assessment process for its guidelines, and similarities were found between ILCOR work and that of the WHO. Thanks must go to the WHO representatives and associated clinicians for their informed and helpful input into discussions about subjects common to both groups.
The values, preferences, and task force insights section after each treatment recommendation section presents the prioritization of outcomes in the decision-making processes and the considerations that informed the direction and strength of the treatment recommendations.10
Section snippets
Evidence reviews addressing questions related to the prearrest State
Although survival from pediatric cardiac arrest is improving in many (but not all) parts of the world,11, 12, 13 especially in the in-hospital setting, the recognition and early treatment of infants and children with deteriorating conditions remains a priority to prevent cardiac arrest.
This section contains the following reviews:
Basic life support care
The major difference between council recommendations for basic life support (BLS) care is the sequence of CPR (C–A–B versus A–B–C) and the upper limit on recommendation for chest compression rate. All other recommendations in this area are similar between councils. Adult BLS currently places greater emphasis on high-quality chest compressions than on the complex interplay of chest compressions and rescue breaths, with the rationale of simplifying lay rescuer education and increasing the rate of
Advanced life support during arrest
Advanced life support (ALS) as part of cardiac arrest care builds on high-quality CPR by monitoring a patient's physiology and response to BLS, recognizing and intervening for life-threatening arrhythmias, and optimizing perfusion by medication or mechanical support. Frequent monitoring of the patient's physiologic response to these interventions allows individual titration of care with the goal of optimizing outcome.
Not all patients will respond to standard BLS and ALS care, and escalation to
Post-ROSC care
The postresuscitation care section focuses on specific interventions and predictive factors to optimize the recovery of children after cardiac arrest and ROSC.
While the scope of postresuscitation syndrome care is broad, the Pediatric Task Force limited their evidence review to six topics. These are highlighted in Table 1 and include the following:
Disclosures
2015 CoSTR Part 6: Pediatric Basic Life Support and Pediatric Advanced Life Support: Writing Group DisclosuresWriting group member Employment Research grant Other research support Speakers’ bureau/honoraria Expert witness Ownership interest Consultant/advisory board Other Ian K. Maconochie St. Mary's Hospital None None None None None None None Allan R. de Caen University of Alberta and Stollery Children's Hospital None None None None None None None Richard Aickin Starship Children's Hospital None None None None None None None
Acknowledgments
We thank the following individuals (Pediatric Basic Life Support and Pediatric Advanced Life Support Chapter Collaborators) for their collaborations on the systematic reviews contained in this section.
References (105)
- et al.
Implementation and impact of a rapid response team in a children's hospital
Jt Comm J Qual Patient Saf
(2007) - et al.
Verification of changes in the time taken to initiate chest compressions according to modified basic life support guidelines
Am J Emerg Med
(2013) - et al.
Comparison of times of intervention during pediatric CPR maneuvers using ABC and CAB sequences: a randomized trial
Resuscitation
(2012) - et al.
2010 American heart association recommended compression depths during pediatric in-hospital resuscitations are associated with survival
Resuscitation
(2014) - et al.
Depth of sternal compression and intra-arterial blood pressure during CPR in infants following cardiac surgery
Resuscitation
(2009) - et al.
Pushing harder, pushing faster, minimizing interruptions… but falling short of 2010 cardiopulmonary resuscitation targets during in-hospital pediatric and adolescent resuscitation
Resuscitation
(2013) - 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) - et al.
Pediatric defibrillation doses often fail to terminate prolonged out-of-hospital ventricular fibrillation in children
Resuscitation
(2005) - et al.
Shockable rhythms and defibrillation during in-hospital pediatric cardiac arrest
Resuscitation
(2014) - et al.
Energy doses for treatment of out-of-hospital pediatric ventricular fibrillation
Resuscitation
(2006)
Hemodynamic directed CPR improves short-term survival from asphyxia-associated cardiac arrest
Resuscitation
Outcomes associated with amiodarone and lidocaine in the treatment of in-hospital pediatric cardiac arrest with pulseless ventricular tachycardia or ventricular fibrillation
Resuscitation
Effect of adrenaline on survival in out-of-hospital cardiac arrest: a randomised double-blind placebo-controlled trial
Resuscitation
Outcome of infants requiring cardiopulmonary resuscitation before extracorporeal membrane oxygenation
J Pediatr Surg
Survey of outcome of CPR in pediatric in-hospital cardiac arrest in a medical center in Taiwan
Resuscitation
A prospective study of outcome of in-patient paediatric cardiopulmonary arrest
Resuscitation
Therapeutic hypothermia associated with increased survival after resuscitation in children
Pediatr Neurol
Evolution, safety and efficacy of targeted temperature management after pediatric cardiac arrest
Resuscitation
Hyperoxia, hypocapnia and hypercapnia as outcome factors after cardiac arrest in children
Resuscitation
Post-resuscitative clinical features in the first hour after achieving sustained ROSC predict the duration of survival in children with non-traumatic out-of-hospital cardiac arrest
Resuscitation
QUADAS-2: a revised tool for the quality assessment of diagnostic accuracy studies
Ann Intern Med
Grading quality of evidence and strength of recommendations in clinical practice guidelines part 3 of 3. The GRADE approach to developing recommendations
Allergy
Survival trends in pediatric in-hospital cardiac arrests: an analysis from get with the guidelines-resuscitation
Circ Cardiovasc Qual Outcomes
Duration of cardiopulmonary resuscitation and illness category impact survival and neurologic outcomes for in-hospital pediatric cardiac arrests
Circulation
Trends in PICU admission and survival rates in children in Australia and New Zealand following cardiac arrest
Pediatr Crit Care Med
A reduction in cardiac arrests and duration of clinical instability after implementation of a paediatric rapid response system
Qual Saf Health Care
Implementation of a medical emergency team in a large pediatric teaching hospital prevents respiratory and cardiopulmonary arrests outside the intensive care unit
Pediatr Crit Care Med
Transition from a traditional code team to a medical emergency team and categorization of cardiopulmonary arrests in a children's center
Arch Pediatr Adolesc Med
Reduction of hospital mortality and of preventable cardiac arrest and death on introduction of a pediatric medical emergency team
Pediatr Crit Care Med
Implementation of a multicenter rapid response system in pediatric academic hospitals is effective
Pediatrics
Experience of pediatric rapid response team in a tertiary care hospital in Pakistan
Indian J Pediatr
Impact of rapid response system implementation on critical deterioration events in children
JAMA Pediatr
Effect of a rapid response team on hospital-wide mortality code rates outside the ICU in a children's hospital
JAMA
A multicenter collaborative approach to reducing pediatric codes outside the ICU
Pediatrics
A reduction in cardiac arrests and duration of clinical instability after implementation of a paediatric rapid response system
Postgrad Med J
Cost-benefit analysis of a medical emergency team in a children's hospital
Pediatrics
Reduction in hospital mortality over time in a hospital without a pediatric medical emergency team: limitations of before-and-after study designs
Arch Pediatr Adolesc Med
Implementing sustaining evidence-based nursing practice to reduce pediatric cardiopulmonary arrest
West J Nurs Res
Management and outcomes in pediatric patients presenting with acute fulminant myocarditis
J Pediatr
Atropine for critical care intubation in a cohort of 264 children and reduced mortality unrelated to effects on bradycardia
PLoS One
The effect of atropine on rhythm and conduction disturbances during 322 critical care intubations
Pediatr Crit Care Med
Pediatric rapid sequence intubation: incidence of reflex bradycardia and effects of pretreatment with atropine
Pediatr Emerg Care
Cited by (0)
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2015 International Consensus on Cardiopulmonary Resuscitation and Emergency Cardiovascular Care Science with Treatment Recommendations.
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This article has been copublished in Circulation. This article has also been reprinted in Pediatrics.
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Co-chairs and equal first authors.
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See Acknowledgements for the list of members in Pediatric basic life support and pediatric advanced life support Chapter Collaborators.