A summary of the changes in paediatric and neonatal resuscitation guidelines from the International Liaison Committee on Resuscitation document

The International Liaison Committee on Resuscitation published its first evidence-based medicine analysis of resuscitation science in 2000 (1). The translation of science into resuscitation guidelines has been done by resuscitation councils from different countries. Since the release of the guidelines in 2000, the Heart and Stroke Foundation of Canada has participated as one of the council members within the International Liaison Committee on Resuscitation and partnered with the American Heart Association to generate guidelines that are relevant to North America. Progress in resuscitation science has led to changes in guidelines for the care of acutely ill neonates and children. Assisted ventilation can reduce the effectiveness of cardiopulmonary resuscitation (CPR). The time needed to deliver rescue breaths reduces the maximally achievable number of chest compressions (2). Rescue breathing also reduces cardiac output during CPR through positive pressure ventilation's effect of increasing intrathoracic pressures (3).These mechanisms reduce coronary perfusion pressure (a surrogate marker for effective CPR). Paediatric animal data confirm ventilation's more important role in resuscitation from asphyxial cardiopulmonary arrest (CPA), the most common etiology of paediatric CPA (4), than in primary cardiac etiologies of CPA (5). Finally, researchers have made the ‘educational’ argument that a ‘universal algorithm’ with a single compression to ventilation ratio (C:V) for children and adults may increase the likelihood that out-of-hospital bystander CPR would be provided for patients of all ages, with an overall increased ‘survival benefit’ to society in general. The new guidelines advise that the lay rescuer (one-rescuer CPR) provide CPR to adults and children (beyond the newly born) using a C:V of 30:2. Health care providers (two-rescuer CPR) should provide a C:V of 15:2 for all children (with the exception of newborn babies). High-dose adrenaline (0.1 mg/kg) has frequently been used to treat paediatric CPA that was refractory to standard-dose adrenaline (0.01 mg/kg). A recent large prospective randomized controlled trial (6) showed that children in CPA who received high-dose intravenous adrenaline showed no survival benefit. Additionally, post hoc analysis suggested increased neurological morbidity in those survivors of asphyxial CPA who had been treated with high-dose adrenaline. There is a clear need to de-emphasize the role for high-dose adrenaline in resuscitation. Literature examining vasopressin's use in the resuscitation of paediatric CPA is limited to animal studies and a single paediatric case series (7). Its role in paediatric resuscitation remains unclear and awaits the results of further study. Endotracheal (ET) drug dosing is plagued by inconsistent absorption and often detrimental pharmacokinetics. Examples include the sustained postresuscitation hypertension that occurs due to intrapulmonary adrenaline depot effects (8), or the diastolic (and consequent coronary arterial) hypotension resulting from beta-mediated effects of the doses of ET adrenaline previously suggested by the Advanced Cardiac Life Support and Neonatal Resuscitation Program (9). Conversely, studies of intraosseous drug delivery show efficacy in populations ranging from infants to adults, often with the use of new delivery devices that have recently become commercially available (eg, bone injection guns and sternal screw devices). While ET drug delivery remains an option for vascular access, its use should be reserved for the rare occasion that intravenous access and devices (including intraosseous needles) have been attempted and failed. End-tidal CO2 detection is an accepted standard for confirming the appropriate placement of ET tubes after intubation. Its use is now also suggested for monitoring ET tube position during patient transport (pre-, intra-or interhospital), observing for possible tube displacement. ET CO2 monitoring is more rapid and sensitive than pulse oximetry in confirming tube malposition (10). Uncuffed ET tubes have long been used in small children for anatomical reasons, including concerns that tube cuffs contributed to subglottic injury. Studies now suggest that cuffed ET tubes are safe to use in small children, and may be beneficial, especially in the setting of significant lung disease (reduced lung compliance or increased airway resistance) (11). However, attention must be paid to tracheal tube size, position and cuff pressure. Improved neurological outcome has been demonstrated in adult CPA victims treated with moderate hypothermia (32°C to 34°C) after successful CPR (12,13). There is still conflict in the neonatal hypoxic-ischemic encephalopathy literature in regard to the therapeutic role of hypothermia. Despite a paucity of specifically paediatric literature, the adult data, coupled with compelling animal-based studies, support the use of therapeutic hypothermia (32°C to 34°C for 12 h to 24 h) as part of the critical care of children that remain comatose after resuscitation from CPA. Ongoing studies will hopefully clarify the best technique for cooling and show positive outcome data specifically in children. Animal and human (adult) data suggest that biphasic defibrillation is more effective than monophasic waveforms in electrically converting ventricular fibrillation and pulseless ventricular tachycardia, with less resultant myocardial injury. Paediatric studies are limited to animal studies and one human case series, but have supported the suggested efficacy of biphasic waveforms for paediatric defibrillation (14). Proposed initial doses of 2 J/kg as monophasic or biphasic shocks are acceptable, with escalation to 4 J/kg for single-shock resistant rhythms. Routine intrapartum suctioning of infants born to mothers with meconium-stained amniotic fluid is no longer recommended (15). Premature very low birth weight infants remain at risk for hypothermia. Randomized controlled trials suggest that covering the baby with plastic bags (food-grade and heat-resistant) or plastic wrapping significantly improves the admission temperature of premature babies younger than 28 weeks (16). Although a meta-analysis (17,18) of four human studies showed a reduction in mortality, with no evidence of harm to infants resuscitated with air compared with 100% oxygen, there were significant methodological concerns; thus, these results must be viewed with caution. Supplemental oxygen should be used whenever positive pressure ventilation is indicated or when there is no appreciable improvement in colour after 90 s. There is insufficient evidence to specify what concentration of oxygen should be used for initial resuscitation (19). When properly performed, positive pressure ventilation alone is effective in resuscitating almost all apneic or bradycardic newborn infants. The primary measure of adequate ventilation is prompt improvement in heart rate (20,21) The presence or absence of chest wall movement has been described but not assessed. Establishing effective ventilation must be the primary objective in the management of the apneic or bradycardic newborn infant. The initial peak inflating pressures needed are variable and should be individualized. Pressures of 30 cm H2O to 40 cm H20 or higher may be required for some babies (22,23). In the sick neonate, continuous positive airway pressure (CPAP) helps stabilize and improve lung function (24). Excessive CPAP can cause overdistension of the lungs, and increase the work of breathing and decrease cardiac output (25). In spontaneously breathing preterm infants, CPAP may be beneficial after resuscitation (19). Effective ventilation can be achieved with either a flow-inflating or self-inflating bag or with a T-piece mechanical device designed to regulate pressure. The popoff valves of self-inflating bags are flow dependant and the pressures generated may exceed the value specified by the manufacturer. Target inflation pressures and long inspiratory times are more consistently achieved in mechanical models using T-piece devices (26); however, the clinical implications are unclear. Laryngeal mask airways (LMAs) that fit over the laryngeal inlet have been shown to be effective for ventilating newborn infants (27). There are no data comparing LMAs with bag mask ventilation. There are insufficient data to support routine use of LMAs; however, they should be used to provide an adjunct airway when bag and mask ventilation is unsuccessful and intubation is either not feasible or unsuccessful. CO2 detection is effective for confirmation of ET tube placement (28). Poor or absent pulmonary blood flow may give false-negative results, but tracheal tube placement is correctly identified in nearly all infants who are not in CPA (28). ET tube placement must be assessed by confirmatory methods if the heart rate does not rise. Exhaled CO2 detection is the recommended method of confirmation (19). Given the paucity of high-quality data regarding ET administration of adrenaline, it is recommended that the intravenous route be used as soon as venous access is established. The recommended intravenous dose is 0.01 mg/kg to 0.03 mg/kg. Limited evidence suggests that doses up to 0.1 mg/kg should be considered by the ET route. However, the safety and efficacy of this have not been established. There are insufficient data to recommend routine use of modest systemic or selective cerebral hypothermia after resuscitation of infants with suspected asphyxia (19). For withholding resuscitation, a consistent and coordinated approach to individual cases by the parents and neonatal and obstetric teams is required. The following guidelines should be interpreted according to current regional outcomes and societal principles: Where gestation, birth weight or congenital anomalies are associated with almost certain death, and unacceptably high morbidity is likely among rare survivors, resuscitation is not indicated. In conditions associated with an uncertain prognosis, borderline survival and high morbidity, and where the burden to the child is high, parental desires regarding initiation of resuscitation should be supported. After 10 min of continuous and adequate resuscitation efforts, discontinuation of resuscitation may be justified if there are no signs of life. The evidence-based medicine worksheets and relevant references addressing the scientific advances that have led to the suggested guidelines can be viewed on-line at . The authors were members of the International Liaison Committee on Resuscitation review committees

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