The ERC Guidelines 2021: Paediatric Life Support (7/7)

Many underlying aetiologies and pathophysiological processes in paediatric critical illness differ from those in adults. The ERC 2021 Guidelines, devote an entire chapter to the topic.

Paediatric Life Support: A critical topic, as intensivists may have limited experience with such cases

Critical illness is less common in children and intensivists may have limited experience with such cases. Many of the underlying aetiologies and pathophysiological processes involved differ from those in adults. Therefore, the ERC 2021 Guidelines, as in the past, devote an entire chapter to paediatric cardiopulmonary resuscitation.

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The ERC Guidelines 2021 pay great attention to the management of infants and children with cardiac arrest. The ERC paediatric guidelines apply to all paediatric patients, whether neonates, infants, children, from 0 to 18 years. These do not apply to resuscitation of the newborn in the delivery room, for which there is a specific chapter. They do not apply to children who look like adults (adult guidelines are used). There are relatively few major changes from the 2015 guidelines. Some key points to highlight are:

• Oxygen therapy should aim for an SpO₂ of 94-98% - until saturation management is possible. In children with signs of circulatory/respiratory failure where SpO₂ (or PaO₂) cannot be measured, start oxygen at high flows.
   
• In children with circulatory failure, a. administer 1 or more fluid boluses (10 ml/kg) b. reassess after each bolus to avoid fluid overload, c. administer vasoactive drugs early, d. limit boluses of crystalloid solutions and, as soon as available, e. administer blood products (whole blood or red blood cells packed with plasma and platelets) in case of haemorrhagic shock.
   
• The importance for healthcare professionals to actively seek out (and treat) reversible causes of cardiac arrest is emphasised.
   
• 2-operator AMBU (Auxiliary Manual Breathing Unit) balloon ventilation is the first line of ventilatory support during CPR for all competent caregivers; only if the patient is intubated, asynchronous ventilation is recommended, and this at an age-appropriate rate (10-25 per minute).

Credit: ERC

The following is a summary of the new elements (and some confirmations) prepared by Dr. Martin Fandler (Sozialstiftung Bamberg, Bamberg) in the paediatric management of cardiac arrest.

Compression-ventilation ratio

15:2 applies to all (!) children who have left the delivery room (= from a few hours to adolescence). 3:1 applies only in the immediate peri-partum period. The guidelines for adult patients can be applied if the child has an "adult appearance".

Energy for defibrillation

4 J/kg is recommended (unlike the AHA - American Heart Association guidelines - , which recommends 2 J/kg initially, and only then 4J/kg). In the case of persistent pulseless ventricular tachycardia (pVT) and ventricular fibrillation (VF) (≥6 shocks), increase to a maximum of 8 J/kg or 360 J.

Access

Intravenous access is the primary access, but no time should be wasted if this access is not available. In this case, intraosseous access is performed early.

Ventilation

Ventilation frequency according to the 15:2 ratio with AMBU bag. With intubation or laryngeal mask, the ventilation rate is adjusted according to age:

• <1 year: 25/min
• >1 year - 8 years: 20/min
• >8 years - 12 years: 15/min
• >12 years: 10/min

Mask positioning optimised as much as possible: double C-clamp. Initial ventilation only if the AMBU is immediately available. Otherwise, do not wait and start compressions immediately. Oxygen: 100% FiO₂ (unchanged, but there remains some controversy over hyperoxygenation).

Airway protection

Mainly ventilation with AMBU bag, intubation only at ROSC. In the initial phase endotracheal intubation should only be performed by competent personnel, following a well-defined procedure, and having the necessary materials and medications. The decision to proceed with intubation should always be balanced against the risk associated with the procedure.

The use of cuffed tubes is recommended (e.g. to avoid errors in tube selection, to improve the accuracy of capnography, to safely administer current volumes, to reduce the rate of aspiration, to reduce the number of tube changes required, for standardisation).

Credit: ERC

The ERC 2021 Guidelines present a major update on cardiopulmonary resuscitation and provide the most up-to-date evidence-based procedures for citizens (lay professionals), healthcare professionals and health policy makers across Europe. The ERC Guidelines 2021 can be downloaded here: New ERC Guidelines.

An overview of the most important ECR Guidelines 2021 changes is available in this esanum article series:

• The ERC Guidelines 2021 (Part 1/7)
• Main Changes (Part 2/7)
• Adult Advanced Life Support (ALS) (Part 3/7)
• Peri-Arrest Arrhythmias (Part 4/7)
• Cardiac Arrest in Special Circumstances (Part 5/7)
• Post-Resuscitation Care (Part 6/7)
• Resuscitation in Children (Part 7/7)

Sources:
1. Van de Voorde P, Turner NM, Djakow J, de Lucas N, Martinez-Mejias A, Biarent D, Bingham R, Brissaud O, Hoffmann F, Johannesdottir GB, Lauritsen T, Maconochie I. European Resuscitation Council Guidelines 2021: Paediatric Life Support. Resuscitation. 2021 Apr;161:327-387. doi: 10.1016/j.resuscitation.2021.02.015. Epub 2021 Mar 24. PMID: 33773830.
2. Fandler M. Neue Reanimationsleitlinien 2021 (ERC) Zusammenfassung. Nerdfallmedizin.de. 25/03/2021