By University of Virginia Health System emergency physician Joshua Easter, MD, MSc
The American Heart Association (AHA) recently published new guidelines for pediatric advanced life support (PALS) (Merchant, 2020). There are major changes to ventilation rates for arrest and fluid boluses for septic shock, as well as a few more minor revisions that will impact your resuscitation of children in the ED.
Major changes include:
1. Increase in respiratory rate for children in arrest to 20-30 breaths per minute
For children in cardiac arrest with an advanced airway in place, e.g., endotracheal tube, the guidelines now recommend increasing the respiratory rate to 20-30 breaths per minute or 1 breath every 2 to 3 seconds. This is a significant increase from the prior recommendation of administering the same 10 breaths per minute for intubated children as adults. Prior recommendations in children were based on the extrapolation of data from adults and pigs. Recently, a multi-center observational study of 52 pediatric in-hospital cardiac arrests found higher ventilation rates were associated with return of circulation (OR=4.6; 95% CI, 1.3-16), survival to discharge (OR=4.7; 95% CI, 1.2-19), and survival with a favorable neurologic outcome (OR=4.7; 95% CI, 1.2-19) (Sutton, 2019). These effects persisted when controlling for several potential confounders.
It is unclear how well this study of in-hospital arrest translates to the ED. The study was small, and nearly 3/4s of children had an initial rhythm of bradycardia with poor perfusion, which is less common in the ED. The International Liaison Committee on Resuscitation (ILCOR) published revised guidelines for pediatric resuscitation recently and did not find the data on respiratory rates sufficient to alter their recommendation of 10 breaths per minute for children in arrest (Maconochie, 2020). Nevertheless, the conclusions from the study cited by the AHA seem consistent with the unique respiratory physiology of children compared to adults; children are more likely to have a respiratory etiology for their arrest, and they higher basal respiratory rates. The AHA guidelines also now recommend utilizing a similar respiratory rate of 20-30 breaths per minute to assist children with inadequate ventilations but a pulse.
Physicians should continue to be vigilant about ensuring that ventilations do not exceed 30 breaths per minute during arrest, as these supra-normal rates may inhibit venous return and increase intracranial pressure.
2. Titrating bolus intravenous fluids for septic shock
For children with suspicion of infection and shock (i.e., blood pressure <5th percentile for age), the AHA now recommends administering a 10-20 ml/kg bolus initially with frequent reassessments to determine the need for further intravenous fluids. Previously, the AHA advocated administering 20 ml/kg of fluid to all patients. The revision stems from a multi-center randomized control trial comparing the impact of a 10 ml/kg versus 20 ml/kg intravenous fluid bolus for 73 children presenting to the ED with septic shock (Inwald, 2019).There was no difference between the two groups in multiple outcomes, including mortality, duration of hospitalization, and need for mechanical ventilation.
It is surprising that the AHA elected to revise their guidelines based on this small pilot study, which was under-powered. The International Liaison Committee on Resuscitation (ILCOR) did not amend their recommendation in 2020 to give 20 ml/kg of fluids initially (Maconochie, 2020).
Regardless, of the amount of fluids administered, it is important to reassess the patient after each bolus to evaluate for signs of fluid overload, including pulmonary edema with tachypnea or new hepatomegaly. Children may require 40-60 ml/kg of intravenous fluids in the first hour, and fluids should be administered until vital signs and signs of perfusion improve, or children develop fluid overload. The 2020 Surviving Sepsis Guidelines distinguish between treatment of children in settings with and without pediatric intensive care capabilities (Weiss, 2020). If an ICU is available, they recommend administering 10-20 ml/kg boluses up to 40-60 ml/kg in the first hour. If an ICU is not available, they recommend being more cautious with fluid administration and limiting the total over the first hour to 40 ml/kg.
Less impactful AHA revisions include:
1. No dopamine for septic shock
Two small randomized control trials showed dopamine resulted in less rapid resolution of shock, higher sequential organ failure scores, and higher mortality compared to epinephrine. This change to the AHA guidelines is consistent with the 2020 Surviving Sepsis Guidelines, which recommend epinephrine or norepinephrine over dopamine. Administration of these vasopressors through a peripheral IV catheter is reasonable until a central venous catheter can be placed, which is often in the ICU.
2. Cuffed endotracheal tubes for all intubations
Cuffed endotracheal tubes lead to less aspiration, need for tube exchange, and reintubation compared to uncuffed tubes. The concern of subglottic stenosis from cuffed tubes appears overblown, and the AHA now recommends cuffed endotracheal tubes for children of all ages.
3. No cricoid pressure for intubation
Cricoid pressure reduces the likelihood of success with pediatric intubation. Children’s tracheas are more complaint and apt to occlusion with cricoid pressure. The AHA no longer recommends routine cricoid pressure; although, if a physician is having difficulty visualizing the vocal cords without cricoid pressure, it remains reasonable to attempt cricoid pressure briefly to improve intubating conditions.
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