Paediatric (and Neonatal) Resuscitation : What has changed and why?

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Dr Michael Clifford MBBS(Hons), FANZCA,FJFICM
Department of Anaesthesia and Pain Management and the Paediatric Intensive Care Unit
Royal Children’s Hospital, Melbourne, Australia

2005 saw the release of the Consensus on Science and Treatment Recommendations by the International Liaison Committee on Resuscitation (ILCOR)1 following a complex review process 2 and these were published simultaneously in Resuscitation, Circulation and Pediatrics . The European Resuscitation Council (ERC) issued the response of the Paediatric Life Support Working Party soon after 3 and the Australian Resuscitation Council (ARC) a summary in Critical Care and Resuscitation in June 2006 4,5,6.

These publications reflect an attempt to allow various resuscitation councils and organisations throughout the world to develop their own guidelines “incorporating whatever local nuances or priorities are necessary..”4 and include some substantive changes to the resuscitation algorithms.

These changes reflect an enormous amount of work by the representatives of the ILCOR Pediatric taskforce aiming to review “all pertinent studies” for a “convincing scientific evidence base”7.It was recognised that there is a “paucity of sound studies”, and many recommendations have been extrapolated from adult data, animal research and “expert opinion consensus” rather than specific high quality randomised controlled trials7.

Nonetheless many recommendations follow exhaustive literature searches with sound methodologies and highly specific questions. These informative “Worksheets” are excellent summaries of published information on many topics and are available in full (along with conflict of interest statements) via the American Heart Association website.

The importance of simplification in order to assist in teaching and retention for lay rescuers provided the impetus to study the feasibility of applying the same guidelines for children and adults3 has led to the emergence of the “Universal Algorithm”1,3,4 . The importance of early recognition, timely intervention and high quality post-resuscitative care are linked as the “Chain of Survival” .

Recognition of the importance of maintenance of coronary perfusion and hence the need to provide (almost) uninterrupted chest compressions has seen changes to both Basic and Advanced Life Support. These include the recommendation to continue compressions for 2 minutes AFTER successful cardioversion, attempting to assist rather than “stand back and watch an exhausted heart try to beat”8

This “Universal Algorithm” does however require modification when advanced resuscitation is being provided by health care personnel in particular the child in hospital theatre who may be surrounded by staff skilled in the provision of advanced resuscitative techniques. Some older agents have had their role and doses adjusted1 and whilst some newer therapeutic agents have firmed others remain controversial9. The area is dynamic and continues to evolve with more recent observations specific to anaesthetic care .

Defibrillatory monophasic salvo’s have (almost) been replaced by single biphasic shocks although optimal energy levels remain unclear1,3,6. Despite the “consensus” some differences between the major organisations remain – in particular the continued use of an initial three shock salvo for witnessed arrest in Australia.

This presentation will concentrate on the changes and those controversies with emphasis on the in-hospital responses of significance to the practising paediatric anaesthetist or the consultant anaesthetist who may be called upon to facilitate the resuscitation of the child or newborn10.

The ARC has been keen to stress that during the transition period of implementation “existing practise should not be considered to be either ineffective or unsafe…(nor) that what we have been doing previously is either wrong or harmful, but rather that we may be able to do better.”4

In continuing to attempt to provide the best consensus evidence-based-guidelines they (the ARC) aim to provide a response to the request: “Tell us what you want (us) to do and when, but be honest about the amount (or lack) of information you have to support it”. (For further information see http://www.resus.org.au.)

References

1. Proceedings of the 2005 International Consensus on Cardiopulmonary Resuscitation and Emergency Cardiovascular Care Science with Treatment Recommendations. Resuscitation 2005;67: 157-341
2. Morley PT, Zaritsky A. The evidence evaluation process for the 2005 International Consensus on Cardiopulmonary Resuscitation and Emergency Cardiovascular Care Science with Treatment Recommendations. Resuscitation 2005;67: 167-170
3. Biarent D, Bingham R, etal. European Resuscitation Council Guidelines for Resuscitation 2005 Section 6. Paediatric life support. Resuscitation 2005; 67 S1, S97-S133
4. Jacobs IG, Morley PT. The Australian Resuscitation Council: new guidelines for 2006. Editorial. Crit Care Resusc 2006; 2: 87-88
5. Tibballs J. Australian Resuscitation Council: paediatric advanced life support(PALS) guidelines 2006. Crit Care Resusc 2006; 2: 132-134
6. Morley PT, Walker T. Australian Resuscitation Council: adult advanced life support (ALS) guidelines Crit Care Resusc 2006; 2: 129-131
7. Sarti A. New Pediatric resuscitation guidelines: new evidence or new ideas? Editorial. Pediatric Anesthesia 2006; 16: 607-610
8. Pafitt A. Resuscitation Guidelines. Editorial. The Lancet 2006; 367: 283-4
9. Moran JL, Solomon PJ. Therapeutic hypothermia for cardiac arrest – once again. Crit Care Resusc 2006; 2: 151-154
10. Morley C. New Australian Neonatal Resuscitation guidelines. Journal of Paediatrics and Child Health 2007; 43: 6-8

Time of Presentation
1530