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Background: Annually 15,200 children suffer an in-hospital cardiac arrest (IHCA) in the US. Ventricular fibrillation or pulseless ventricular tachycardia (VF/pVT) is the initial rhythm in 10-15% of these arrests. We sought to evaluate the association of number of shocks and early dose escalation with survival for initial VF/pVT in pediatric IHCA., Methods: Using 2000-2020 data from the American Heart Association's (AHA) Get with the Guidelines®-Resuscitation (GWTG-R) registry, we identified children >48 hours of life and ≤18 years who had an IHCA from initial VF/pVT and received defibrillation., Results: There were 251 subjects (37.7%) who received a single shock and 415 subjects (62.3%) who received multiple shocks. Baseline and cardiac arrest characteristics did not differ between those who received a single shock versus multiple shocks except for duration of arrest and calendar year. The median first shock dose was consistent with AHA dosing recommendations and not different between those who received a single shock versus multiple shocks. Survival was improved for those who received a single shock compared to multiple shocks. However, no difference in survival was noted between those who received 2, 3, or ≥4 shocks. Of those receiving multiple shocks, no difference was observed with early dose escalation., Conclusions: In pediatric IHCA, most patients with initial VF/pVT require more than one shock. No distinctions in patient or pre-arrest characteristics were identified between those who received a single shock versus multiple shocks. Subjects who received a single shock were more likely to survive to hospital discharge even after adjusting for duration of resuscitation., Competing Interests: Declaration of competing interest The authors declare the following financial interests/personal relationships which may be considered as potential competing interests: ‘Tia Raymond reports she is a paid consultant of New England Research Institutes, Inc., as a member of the adjudication committee for the COMPASS Trial (Comparison of Methods for Pulmonary Blood Flow Augmentation in Neonates: Shunt versus Stent. Dianne Atkins reports she is a paid member of the Data Monitoring Safety Board for the Pediatric Heart Network, a multicenter study funded by NHLBI’., (Copyright © 2024 The Author(s). Published by Elsevier B.V. All rights reserved.)

The International Liaison Committee on Resuscitation engages in a continuous review of new, peer-reviewed, published cardiopulmonary resuscitation and first aid science. Draft Consensus on Science With Treatment Recommendations are posted online throughout the year, and this annual summary provides more concise versions of the final Consensus on Science With Treatment Recommendations from all task forces for the year. Topics addressed by systematic reviews this year include resuscitation of cardiac arrest from drowning, extracorporeal cardiopulmonary resuscitation for adults and children, calcium during cardiac arrest, double sequential defibrillation, neuroprognostication after cardiac arrest for adults and children, maintaining normal temperature after preterm birth, heart rate monitoring methods for diagnostics in neonates, detection of exhaled carbon dioxide in neonates, family presence during resuscitation of adults, and a stepwise approach to resuscitation skills training. Members from 6 International Liaison Committee on Resuscitation task forces have assessed, discussed, and debated the quality of the evidence, using Grading of Recommendations Assessment, Development, and Evaluation criteria, and their statements include consensus treatment recommendations. Insights into the deliberations of the task forces are provided in the Justification and Evidence-to-Decision Framework Highlights sections. In addition, the task forces list priority knowledge gaps for further research. Additional topics are addressed with scoping reviews and evidence updates., (Copyright © 2023 The Authors. Published by Elsevier B.V. All rights reserved.)

Objectives: To describe epinephrine dosing distribution using time-stamped data and assess the impact of dosing strategy on survival after ECPR in children., Methods: This was a retrospective study at five pediatric hospitals of children <18 years with an in-hospital ECPR event. Mean number of epinephrine doses was calculated for each 10-minute CPR interval and compared between survivors and non-survivors. Patients were also divided by dosing strategy into a frequent epinephrine group (dosing interval of ≤5 min/dose throughout the first 30 minutes of the event), and a limited epinephrine group (dosing interval of ≤5 min/dose for the first 10 minutes then >5 min/dose for the time between 10 and 30 minutes)., Results: A total of 191 patients were included. Epinephrine was not evenly distributed throughout ECPR, with 66% of doses being given during the first half of the event. Mean number of epinephrine doses was similar between survivors and non-survivors the first 10 minutes (2.7 doses). After 10 minutes, survivors received fewer doses than non-survivors during each subsequent 10-minute interval. Adjusted survival was not different between strategy groups [OR of survival for frequent epinephrine strategy: 0.78 (95% CI 0.36-1.69), p = 0.53]., Conclusions: Survivors received fewer doses than non-survivors after the first 10 minutes of CPR and although there was no statistical difference in survival based on dosing strategy, the findings of this study question the conventional approach to EPCR analysis that assumes dosing is evenly distributed., Competing Interests: Declaration of Competing Interest The authors declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper., (Copyright © 2023 Elsevier B.V. All rights reserved.)

Aims: The primary objective was to determine the association between clinician-reported use of end-tidal CO2 (ETCO2) or diastolic blood pressure (DBP) to monitor cardiopulmonary resuscitation (CPR) quality during pediatric in-hospital cardiac arrest (pIHCA) and survival outcomes., Design: A retrospective cohort study was performed in two cohorts: (1) Patients with an invasive airway in place at the time of arrest to evaluate ETCO2 use, and (2) patients with an arterial line in place at the time of arrest to evaluate DBP use. The primary exposure was clinician-reported use of ETCO2 or DBP. The primary outcome was return of spontaneous circulation (ROSC). Propensity-weighted logistic regression evaluated the association between monitoring and outcomes., Setting: Hospitals reporting to the American Heart Association's Get With The Guidelines®- Resuscitation registry (2007-2021)., Patients: Children with index IHCA with an invasive airway or arterial line at the time of arrest., Results: Between January 2007 and May 2021, there were 15,280 pediatric CPR events with an invasive airway or arterial line in place at the time of arrest. Of 7159 events with an invasive airway, 6829 were eligible for analysis. Of 2978 events with an arterial line, 2886 were eligible. Clinicians reported using ETCO2 in 1335/6829 (20%) arrests and DBP in 1041/2886 (36%). Neither exposure was associated with ROSC. ETCO2 monitoring was associated with higher odds of 24-hour survival (aOR 1.17 [1.02, 1.35], p = 0.03)., Conclusions: Neither clinician-reported ETCO2 monitoring nor DBP monitoring during pIHCA were associated with ROSC. Monitoring of ETCO2 was associated with 24-hour survival., Competing Interests: Declaration of Competing Interest The authors declare the following financial interests/personal relationships which may be considered as potential competing interests: Dr. Vinay Nadkarni is a member of the Editorial Board of Resuscitation., (Copyright © 2023. Published by Elsevier B.V.)

Objective: To characterize chest compression (CC) pause duration during the last 5 minutes of pediatric cardiopulmonary resuscitation (CPR) prior to extracorporeal-CPR (E-CPR) cannulation and the association with survival outcomes., Methods: Cohort study from a resuscitation quality collaborative including pediatric E-CPR cardiac arrest events ≥ 10 min with CPR quality data. We characterized CC interruptions during the last 5 min of defibrillator-electrode recorded CPR (prior to cannulation) and assessed the association between the longest CC pause duration and survival outcomes using multivariable logistic regression., Results: Of 49 E-CPR events, median age was 2.0 [Q1, Q3: 0.6, 6.6] years, 55% (27/49) survived to hospital discharge and 18/49 (37%) with favorable neurological outcome. Median duration of CPR was 51 [43, 69] min. During the last 5 min of recorded CPR prior to cannulation, median duration of the longest CC pause was 14.0 [6.3, 29.4] sec: 66% >10 sec, 25% >29 sec, 14% >60 sec, and longest pause 168 sec. Following planned adjustment for known confounders of age and CPR duration, each 5-sec increase in longest CC pause duration was associated with lower odds of survival to hospital discharge [adjusted OR 0.89, 95 %CI: 0.79-0.99] and lower odds of survival with favorable neurological outcome [adjusted OR 0.77, 95 %CI: 0.60-0.98]., Conclusions: Long CC pauses were common during the last 5 min of recorded CPR prior to E-CPR cannulation. Following adjustment for age and CPR duration, each 5-second incremental increase in longest CC pause duration was associated with significantly decreased rates of survival and favorable neurological outcome., (Copyright © 2022 The Author(s). Published by Elsevier B.V. All rights reserved.)

Aim: Cardiopulmonary resuscitation (CPR) in hospitalized infants is a relatively uncommon but high-risk event associated with mortality. The study objective was to identify factors associated with mortality and survival among infants who receive CPR in the neonatal intensive care unit (NICU) or pediatric intensive care unit (PICU)., Methods: Retrospective observational study of infants with an index CPR event in the NICU or PICU between 1/1/06 and 12/31/18 in the American Heart Association's Get With The Guidelines-Resuscitation registry. Associations between patient, event, unit, and hospital factors and the primary outcome, mortality prior to discharge, were examined using multivariable logistic regression., Results: Among 3521 infants who received CPR, 2080 (59%) died before discharge, with 25% mortality during CPR and 40% within 24 h. Mortality prior to discharge occurred in 65% and 47% of cases in the NICU and PICU, respectively. Factors most strongly independently associated with pre-discharge mortality were vasoactive agent before CPR (adjusted odds ratio (aOR): 2.77, 95% confidence interval (CI) 2.15-3.58), initial pulseless condition (aOR: 2.38, 95% CI 1.46-3.86) or development of pulselessness (aOR: 2.36, 95% CI 1.78-3.12), and NICU location compared with PICU (aOR: 3.85, 95% CI 2.86-5.19). Endotracheal intubation during CPR was associated with decreased odds of pre-discharge mortality (aOR: 0.40, 95% CI 0.33-0.49)., Conclusion: Infants who receive CPR in the intensive care unit experience high mortality rates; identifiable patient, event, and unit factors increase the odds of mortality. Further investigation should explore the association between unit type, resuscitation processes, and mortality., (Copyright © 2021 Elsevier B.V. All rights reserved.)

Background: Current guidelines recommend epinephrine every 3-5min during cardiopulmonary resuscitation. For adults with in-hospital cardiac arrest (IHCA), longer dosing intervals are associated with improved survival to discharge. This study investigates whether longer epinephrine dosing intervals were associated with improved survival to discharge during pediatric IHCA., Methods: Retrospective review of AHA Get With The Guidelines-Resuscitation registry identified 1630 pediatric IHCAs that met inclusion criteria. Average epinephrine dosing interval was defined by dividing duration of resuscitation after first dose of epinephrine by total doses. Average dosing intervals were categorized as 1-5min, >5 to <8min, and 8 to <10min/dose. Primary outcome was survival to hospital discharge. Multivariable logistic regression models controlled for age, gender, illness category, location of arrest, arrest duration, time of day, and time to first epinephrine dose. Secondary analysis separated patients on vasoactive infusion at the time of arrest from those without an infusion in place., Results: Odds ratios (OR) calculated using 1-5min/dose interval as reference. For the total cohort, adjusted OR for survival to hospital discharge for >5 to <8min was 1.81 (95% CI 1.26-2.59), and 8 to <10min 2.64 (95% CI 1.53-4.55). For patients not receiving vasoactive infusion, adjusted OR for survival to discharge for >5 to <8min was 1.99 (95% CI 1.29-3.06) and 8 to <10min 2.67 (95% CI 1.14-5.04)., Conclusions: Longer average dosing intervals than currently recommended for epinephrine administration during pediatric IHCA were associated with improved survival to hospital discharge., (Copyright © 2017 Elsevier B.V. All rights reserved.)

Background: Despite limited recommendations for using sodium bicarbonate (SB) during cardiopulmonary resuscitation (CPR), we hypothesized that SB continues to be used frequently during pediatric in-hospital cardiac arrest (IHCA) and that its use varies by hospital-specific, patient-specific, and event-specific characteristics., Methods: We analyzed 3719 pediatric (<18 years) index pulseless CPR events from the American Heart Association Get With The Guidelines-Resuscitation database from 1/2000 to 9/2010., Results: SB was used in 2536 (68%) of 3719 CPR events. Incidence of SB use between 2000 and 2005 vs. 2006 and 2010 was 71.1% vs. 66.2% (P=0.002). The primary outcome was survival to discharge. Secondary outcomes included 24-h survival and neurologic outcome. Multivariable logistic regression analyzed the association between SB use and outcomes. SB had increased use an ICU location, metabolic/electrolyte disturbance, prolonged CPR, pVT/VF, and concurrently with other pharmacologic interventions. Adjusting for confounding factors, SB use was associated with decreased 24-h survival (aOR 0.83, 95% CI: 0.69, 0.99) and decreased survival to discharge (aOR 0.80; 95% CI: 0.65, 0.97). Inclusion of metabolic/electrolyte abnormalities, hyperkalemia, and toxicologic abnormalities only (n=674), SB use was not associated with worse outcomes or unfavorable neurologic outcome., Conclusions: SB is used frequently during pediatric pulseless IHCA, yet there is a significant trend toward less routine use over the last decade. Because SB is more likely to be used in an ICU, with prolonged CPR, and concurrently with other pharmacologic interventions; its use during CPR may be associated with poor prognosis due to an association with "last ditch" efforts of resuscitation rather than causation., (Copyright © 2015 Elsevier Ireland Ltd. All rights reserved.)