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For this 2020 International Consensus on Cardiopulmonary Resuscitation and Emergency Cardiovascular Care Science With Treatment Recommendations , the Education, Implementation, and Teams Task Force applied the population, intervention, comparator, outcome, study design, time frame format and performed 15 systematic reviews, applying the Grading of Recommendations, Assessment, Development, and Evaluation guidance. Furthermore, 4 scoping reviews and 7 evidence updates assessed any new evidence to determine if a change in any existing treatment recommendation was required. The topics covered included training for the treatment of opioid overdose; basic life support, including automated external defibrillator training; measuring implementation and performance in communities, and cardiac arrest centers; advanced life support training, including team and leadership training and rapid response teams; measuring cardiopulmonary resuscitation performance, feedback devices, and debriefing; and the use of social media to improve cardiopulmonary resuscitation application.

The International Liaison Committee on Resuscitation has initiated a continuous review of new, peer-reviewed, published cardiopulmonary resuscitation science. This is the third annual summary of the International Liaison Committee on Resuscitation International Consensus on Cardiopulmonary Resuscitation and Emergency Cardiovascular Care Science With Treatment Recommendations. It addresses the most recent published resuscitation evidence reviewed by International Liaison Committee on Resuscitation Task Force science experts. This summary addresses the role of cardiac arrest centers and dispatcher-assisted cardiopulmonary resuscitation, the role of extracorporeal cardiopulmonary resuscitation in adults and children, vasopressors in adults, advanced airway interventions in adults and children, targeted temperature management in children after cardiac arrest, initial oxygen concentration during resuscitation of newborns, and interventions for presyncope by first aid providers. Members from 6 International Liaison Committee on Resuscitation task forces have assessed, discussed, and debated the certainty of the evidence on the basis of the 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. The task forces also listed priority knowledge gaps for further research.

PURPOSE Absent cortical somatosensory evoked potentials (SSEPs) reliably predict poor neurologic outcome in adults after cardiac arrest (CA). However, there is less evidence to support this in children. In addition, targeted temperature management, test timing, and a lack of blinding may affect test accuracy. METHODS A single-center, prospective cohort study of pediatric (aged 24 hours to 15 years) patients in which prognostic value of SSEPs were assessed 24, 48, and 72 hours after CA. Targeted temperature management (33-34°C for 24 hours) followed by gradual rewarming to 37°C was used. Somatosensory evoked potentials were graded as present, absent, or indeterminate, and results were blinded to clinicians. Neurologic outcome was graded as "good" (score 1-3) or "poor" (4-6) using the Pediatric Cerebral Performance Category scale 30 days after CA and blinded to SSEP interpreter. RESULTS Twelve patients (median age, 12 months; interquartile range, 2-150; 92% male) had SSEPs interpreted as absent (6/12) or present (6/12)

ObjectiveProlonged admission to a paediatric intensive care unit (PICU) consumes significant healthcare resource. An increase in the number of long-stay admissions and bed utilisation has been reported elsewhere in the world but not in the UK. If an increasing trend of long-stay admissions is evident, this may have significant implications for provision of paediatric intensive care in the future.Design/setting/patientsWe retrospectively analysed prospectively collected data from Birmingham Children’s Hospital, UK, over a 20-year period from 1998 to 2017. PICU admissions, bed-days, length of stay and mortality trends were analysed and reported over four different epochs (1998–2002, 2003–2007, 2008–2012 and 2013–2017) for long-stay admissions (PICU length of stay ≥28 days) and others. Differences in patient demographics, diagnostic categorisation and hospital utilisation were also analysed.ResultsIn total, 24 203 admissions accounted for 131 553 bed-days over the 20-year period. 705 (2.9%) long-stay admissions accounted for 42 312 (32%) bed-days. Proportion of long-stay admissions and corresponding bed-days increased from 1.6% and 20.5% in 1998–2002 to 4.5% and 42.6%, respectively, in 2013–2017 (pConclusionsA significant increase in the proportion of prolonged PICU admissions with disproportionately high resource utilisation and mortality is evident over two decades.

The International Liaison Committee on Resuscitation has initiated a continuous review of new, peer-reviewed, published cardiopulmonary resuscitation science. This is the third annual summary of the International Liaison Committee on Resuscitation International Consensus on Cardiopulmonary Resuscitation and Emergency Cardiovascular Care Science With Treatment Recommendations. It addresses the most recent published resuscitation evidence reviewed by International Liaison Committee on Resuscitation Task Force science experts. This summary addresses the role of cardiac arrest centers and dispatcher-assisted cardiopulmonary resuscitation, the role of extracorporeal cardiopulmonary resuscitation in adults and children, vasopressors in adults, advanced airway interventions in adults and children, targeted temperature management in children after cardiac arrest, initial oxygen concentration during resuscitation of newborns, and interventions for presyncope by first aid providers. Members from 6 International Liaison Committee on Resuscitation task forces have assessed, discussed, and debated the certainty of the evidence on the basis of the 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. The task forces also listed priority knowledge gaps for further research.

To estimate the prevalence of children admitted after out-of-hospital cardiac arrest (OHCA) to UK and Republic of Ireland (RoI) Paediatric Intensive Care Units (PICUs) and factors associated with mortality to inform future clinical trial feasibility.Observational study using a prospectively collected dataset of the Paediatric Intensive Care Audit Network (PICANet) of 33 UK and RoI PICUs (January 2003 to June 2010). Cases (0 to16 years), with documented OHCA surviving to PICU admission and requiring mechanical ventilation were included. Main outcomes were prevalence for admission and death within PICU. Factors associated with mortality were examined with multiple logistic regression analysis.827 of 111,170 admissions (0.73%; 95% CI [0.48 to 0.98%]) were identified as children admitted following OHCA. PICU mortality for OHCA was 50.5% (418/827). Recruitment into an adequately sized clinical trial would not be feasible with the current prevalence rate. Characteristics at PICU admission associated with increased risk of death included; bilateral unreactive pupils, genetically inherited condition, inter-hospital transfer to PICU, requirement for vasoactive drugs and greater base deficit. Factors associated with reduced risk of death were submersion or a respiratory aetiology and pre-existing respiratory or cardiac conditions.Less than 120 children a year are admitted to PICUs in the UK and RoI after OHCA, limiting options for conducting UK intervention trials. The risk factors associated with mortality identified in this study will allow risk stratification in future studies.

Objectives To ascertain current use of therapeutic hypothermia (TH) after paediatric cardiac arrest in UK emergency departments (EDs), and views on participating in a UK randomised controlled trial (RCT) incorporating early induction of TH in ED. Design Anonymous web-based survey of 77 UK Emergency Medicine (EM) consultants from 28 UK EDs that see children during the period April–June 2010. Results 62% (48/77) of surveyed consultants responded from 21/28 (75%) EDs. All managed children post cardiac arrest. 90% (43/48) were aware of the literature concerning TH after cardiac arrest in adults. However, 63% (30/48) had never used TH in paediatric practice. All departments had at least one method of inducing TH (surface cooling; air/water blankets; intravenous cold fluid or catheters). Reasons stated for not inducing TH included no equipment available (26%; 11/42), TH not advocated by the local PICU (24%; 10/42) and not enough evidence for its use (24%; 10/42). TH was considered based on advice from the local Paediatric Intensive Care Units (68%; 17/25) or likelihood of recovery after arrest (32%; 8/25). There was strong support for a UK RCT of TH versus normothermia (85%; 40/47). The proposed RCT was felt to be ethical (87%; 40/48) with use of deferred consent acceptable (74%; 34/46). Conclusion UK EM consultants are aware of TH but infrequently initiate the therapy in children for a number of reasons. Their involvement would enable early induction of TH in EDs after paediatric cardiac arrest during a UK RCT. The authors have demonstrated the availability of suitable equipment and EM consultant support for participation in such a RCT.

Coma may be associated with raised intracranial pressure (ICP), with a causative relationship in some cases. ICP monitoring provides an objective measurement of intracranial pressure and allows the ICP response to specific interventions to be directly observed. A combination of ICP and invasive arterial pressure monitoring provides a measure of the cerebral perfusion pressure (CPP), which is an important parameter in determining cerebral blood flow. Despite widespread use of ICP monitoring in certain causes of coma, most notably traumatic brain injury, the use of ICP monitoring is not proven to improve outcome in any cause of coma. This review explores the current medical literature regarding the uses of ICP monitoring in the paediatric population.

It is unknown whether targeted temperature management (TTM) improves survival after pediatric out-of-hospital cardiac arrest (OHCA). The aim of this study was to assess the evolution, safety and efficacy of TTM (32-34 °C) compared to standard temperature management (STM) (38 °C).Retrospective, single center cohort study. Patients agedone day up to 16 years, admitted to a UK Paediatric Intensive Care Unit (PICU) after OHCA (January 2004-December 2010). Primary outcome was survival to hospital discharge; efficacy and safety outcomes included: application of TTM, physiological, hematological and biochemical side effects.Seventy-three patients were included. Thirty-eight patients (52%) received TTM (32-34 °C). Prior to ILCOR guidance adoption in January 2007, TTM was used infrequently (4/25; 16%). Following adoption, TTM (32-34 °C) use increased significantly (34/48; 71% Chi(2); p0.0001). TTM (32-34 °C) and STM (38 °C) groups were similar at baseline. TTM (32-34 °C) was associated with bradycardia and hypotension compared to STM (38 °C). TTM (32-34 °C) reduced episodes of hyperthermia (38 °C) in the 1st 24h; however, excessive hypothermia (32 °C) and hyperthermia (38 °C) occurred in both groups up to 72 h, and all patients (n = 11) experiencing temperature32 °C died. The study was underpowered to determine a difference in hospital survival (34% (TTM (32-34 °C)) versus 23% (STM (38 °C)); p = 0.284). However, the TTM (32-34 °C) group had a significantly longer PICU length of stay.TTM (32-34 °C) was feasible but associated with bradycardia, hypotension, and increased length of stay in PICU. Temperature32 °C had a universally grave prognosis. Larger studies are required to assess effect on survival.

Providing evidence-based interventions for infants and children is important in paediatric intensive care, where decision making impacts most acutely on morbidity and mortality. However, despite the major progress of medicine in the 21st century, we still lack this evidence for majority of the decisions we make. In this article, we explore and suggest possible solutions for several dilemmas faced by paediatric intensive care researchers. These include ethical dilemmas such as validity of informed consent, use of deferred consent, balancing risk versus benefit and methodological dilemmas such as how to generate high-quality evidence with low-patient volume, choice of valid outcome measures and how best to use research and researchers' networks.

Background Cardiopulmonary arrest in paediatric patients often results in death or survival with severe brain injury. Therapeutic hypothermia, lowering of the core body temperature to 32 °C to 34 °C, may reduce injury to the brain in the period after the circulation has been restored. This therapy has been effective in neonates with hypoxic ischaemic encephalopathy and adults after witnessed ventricular fibrillation cardiopulmonary arrest. The effect of therapeutic hypothermia after cardiopulmonary arrest in paediatric patients is unknown. Objectives To assess the clinical effectiveness of therapeutic hypothermia after paediatric cardiopulmonary arrest. Search methods We searched the Cochrane Anaesthesia Review Group Specialized Register; Cochrane Central Register of Controlled Trials (CENTRAL) (The Cochrane Library 2011, Issue 11); Ovid MEDLINE (1966 to December 2011); Ovid EMBASE (1980 to December 2011); Ovid CINAHL (1982 to December 2011); Ovid BIOSIS (1923 to December 2011); and Web of Science (1945 to December 2011). We searched the trials registry databases for ongoing trials. We also contacted international experts in therapeutic hypothermia and paediatric critical care to locate further published and unpublished studies. Selection criteria We planned to include randomized and quasi-randomized controlled trials comparing therapeutic hypothermia with normothermia or standard care in children, aged 24 hours to 18 years, after paediatric cardiopulmonary arrest. Data collection and analysis Two authors independently assessed articles for inclusion. Main results We found no studies that satisfied the inclusion criteria. We found four on-going randomized controlled trials which may be available for analysis in the future. We excluded 18 non-randomized studies. Of these 18 non-randomized studies, three compared therapeutic hypothermia with standard therapy and demonstrated no difference in mortality or the proportion of children with a good neurological outcome; a narrative report was presented. Authors' conclusions Based on this review, we are unable to make any recommendations for clinical practice. Randomized controlled trials are needed and the results of on-going trials will be assessed when available.

Background and aims Long-stay patients in paediatric intensive care units (PICU) are associated with disproportionately high healthcare resource utilisation and unfavourable outcomes. Increase in long-stay admissions and bed-occupancy have been reported elsewhere but not in the UK. Methods We performed a retrospective analysis of PICU admissions over the last 19 years. Long-stay admissions [length of stay ≥ 28 days] were analysed over 4 different study-periods [1996–2000, 2001–2005, 2006–2010 and 2011–2014]. Chi-square test for trends used for significance tests for trends in proportions. Results 22,059 admission episodes accounted for 108,522 bed-days. 521 long-stay episodes accounted for 30,052 bed-days. Proportion of long-stay admissions and bed-days increased from 1.2% and 19% respectively in 1996–2000, to 3.6% and 36% in 2011–2014 [p Conclusions We found an increasing trend in proportion of long stay patients and bed occupancy. If nationwide figures confirm this trend, PICU capacity planning for the future should take this into account.

Objectives Therapeutic hypothermia improves neurological outcome in adults after ventricular fibrillation cardiac arrest and neonates with hypoxic ischaemic encephalopathy. There is currently no clinical research to support its use in the paediatric population. This survey aims to ascertain current practice in the UK, and attitudes and opinions to guide the feasibility of a UK multicentre, randomised, controlled trial of therapeutic hypothermia after cardiac arrest in children (The Cold-PACK Post Arrest Cooling in Kids study). Methods Anonymous survey of UK paediatric intensive care consultants (n=149). Results A total of 113 (76%) of 149 surveys were returned; 65% responded that they do not know if therapeutic hypothermia improves survival after cardiac arrest. Despite this, 48% ‘always’ or ‘often’ use therapeutic hypothermia after return of spontaneous circulation following cardiac arrest in children. Among those who never use therapeutic hypothermia (33%) the commonest explanation given was ‘not enough research evidence’ (91%). With respect to the dose of therapeutic hypothermia the median duration of cooling used is 24–48 h (range 4–72 h) and median target temperature 34°C to 35°C (range 32°C to 37°C); 68% target a temperature range higher than that applied in the published adult and neonatal studies (33±1°C). There was strong support for a trial of therapeutic hypothermia being ethical (89%) and using deferred consent (85%). Conclusions Wide variation in UK practice in the use of therapeutic hypothermia and a state of clinical equipoise is demonstrated by this survey, which shows important support for UK multicentre collaboration in a future trial of therapeutic hypothermia after cardiac arrest.

Cochrane Review: Hypothermia for neuroprotection in children after cardiopulmonary arrest Scholefield B, Duncan H, Davies P, Gao Smith F, Khan K, Perkins GD, Morris K. Hypothermia for neuroprotection in children after cardiopulmonary arrest. Cochrane Database of Systematic Reviews 2013, Issue 2. Art. No.: CD009442. DOI: 10.1002/14651858.CD009442.pub2 This companion piece to the review, “Hypothermia for neuroprotection in children after cardiopulmonary arrest,” contains the following pieces: The abstract of the review A commentary from one or more of the review authors, explaining why the review team felt the review was an important one to produce A review of clinical practice guidelines from the American Academy of Pediatrics, the Canadian Paediatric Society and the National Institute for Health and Care Excellence (NICE), United Kingdom Some other recently published references on this topic Editor's note on this review, by Ricardo Fernandes: The Editorial Board's rationale for selecting this review was that this is a “classical” case of an important uncertainty in child health. There is a relatively strong rationale for this practice in adults but in pediatrics the underlying condition differs, so extrapolation is controversial. The authors highlight in the abstract that there are ongoing trials, and also mention nonrandomized evidence, all of which is helpful to the reader.

Background There is good evidence that hyperoxia after resuscitation in the newborn period can be detrimental to neurological outcome and survival. The association between hyperoxia and survival after out-of-hospital cardiac arrest (OHCA) in children has not been evaluated. Methods A retrospective, observational study of children admitted to 3 PICUs after OHCA (2004–2010). Primary outcome was survival to hospital discharge. Patients were divided into three groups (hypoxia 40kPa) based on arterial oxygen tension in the first 24 hours. The PaO 2 thresholds used are based on recently published literature. Results 140 patients were identified (51 hypoxia, 60 normoxia, 29 hyperoxia), with the hyperoxia group significantly older than other groups (Table). The predicted probability of death (PIM2) at PICU admission was similar across the three groups, as was the use of interventions, such as transfer between hospitals and requirement for inotropes. Survival to hospital discharge was only 14% (95% CI: 4–31) in the hyperoxia group against 27% (95% CI: 16–40) in the normoxia group and 37% (95% CI: 24–52) in the hypoxia group (p=0.08). The Odds Ratio for survival in the hyperoxia group was 0.44 (95% CI: 0.13–1.46, p=0.18) compared to the normoxia group. Conclusions This study has observed a difference in survival related to oxygen tension status, with a trend to worsening survival from hypoxia through to hyperoxia. Confirmation of this preliminary finding is required in a larger cohort before embarking on a randomised controlled trial.

The International Liaison Committee for Resuscitation recommends that comatose adult patients with spontaneous circulation after cardiac arrest are cooled to 32-34°C for 12-24 hours based on analysis of data from two randomised controlled trials and 17 observational studies.1 However, these studies were mostly in a specific subgroup of cardiac arrest patients with witnessed, out-of-hospital ventricular fibrillation, and evidence of benefit in the general population of cardiac arrest patients has been less certain.2 The rationale for therapeutic hypothermia is that it can reduce cerebral metabolism, attenuate biosynthesis of excitotoxic compounds, reduce free radical production, reduce inflammation, and regulate gene and protein expressions associated with necrotic and apoptotic pathways during ischaemia and reperfusion.3 Recommendations for treatment in children4 (box 1) are based almost solely on adult data. However, the aetiology of cardiac arrest is very different in children,5 possibly altering the pattern of neuronal injury. Most cardiac arrests are secondary to a respiratory cause with profound hypoxia, and primary cardiac causes of arrests, including ventricular fibrillation, are rare. In other clinical situations, therapeutic hypothermia has been seen to be both beneficial (newborns with hypoxic brain injury within 6 hours of birth)6 and potentially harmful (traumatic brain injury).7 It is therefore important that the question of whether children with cardiac arrest should be treated with therapeutic hypothermia is addressed. #### Box 1: Recommendations for use of therapeutic hypothermia after paediatric cardiac arrest (International Consensus on Cardiopulmonary Resuscitation and Emergency Cardiovascular Care Science with Treatment Recommendations4) Our recent Cochrane systematic …

Introduction Survival after paediatric out-of-hospital cardiac arrest (OHCA) is poor, even amongst those who are successfully resuscitated and admitted to PICU. Better prediction of survival would be of benefit to clinical teams and to research teams designing trials. This study aimed to identify predictive factors for survival to inform the design of a post-OHCA intervention trial. Method Retrospective, cohort study of 155 infants and children (1 day to 16 years) admitted to 3 UK PICUs after OHCA (2004–2010). Variables relating to a) the resuscitation period (Utstein) and b) the post-resuscitation period were included in two multivariate stepwise regression models to identify predictive factors for survival to PICU discharge. Results 32% (50/155) children survived to PICU discharge. Resuscitation variables individually associated with improved survival included; presenting in a shockable rhythm, shorter duration of arrest, return of spontaneous cardiac output prior to arrival in the emergency department and lower number of epinephrine doses. Post-resuscitation variables individually associated with improved survival included; higher arterial pH, lower blood lactate, lower maximum glucose, higher base excess and responsive pupils. Results of multivariate stepwise regression models are reported in table. Conclusion This large UK study is the first to identify lactate as one of the key predictors of paediatric OHCA survival in patients admitted to PICU. Development of an accurate prediction tool would assist trial design and prognostication after paediatric OHCA.