**4.6 Neurologic monitoring**

usefulness of hyperoxia after cardiac arrest in children. Treatment with a goal of providing normal paO2 using the lowest possible fraction of inspired oxygen to maintain an oxygen saturation of 94–99% is the current strategy [102]. It is important to manage ventilation as both hypercarbia and hypocarbia have deleterious effects on cerebral perfusion. Current data suggest that it is appropriate to target normocapnia or a PaCO2 specific for the patient's condition while minimizing hypercapnia and hypocapnia [24, 105]. While providing strategies to optimize oxygenation and ventilation, we must be mindful that therapeutic hypothermia can alter the arterial oxygen saturation and affect carbon dioxide production which will

The 2019 American Heart Association update for Pediatric Advanced Life Support included endorsement of post-cardiac arrest continuous maintenance of patient temperature, also referred to as TTM. In 2019 ILCOR pediatric CoSTR summarized evidence supporting the use of TTM (32–34°C) in infants and children after cardiac arrest [107]. Referring to their work, the American Heart Association recommends continuous measurement of core temperature during TTM. Additionally, for infants and children between 24 h of age and 18 years of age who remain comatose after out of hospital cardiac arrest or IHCA, it is reasonable to use TTM at 32–34°C followed by TTM at 36–37.5°C. Initiating hypothermia can be achieve in many ways including cooling blankets, surface cooling with ice packets, or gastric lavage. Electrolyte derangements including hyperglycemia, hypokalemia, hypophosphatemia, hypomagnesaemia, and hypocalcemia can occur during induction of hypothermia. This electrolyte instability can lead to arrhythmias. While maintaining hypothermia, careful monitoring is required. The ideal strategy for rewarming has not yet been identified. In children, the rewarming is usually done at a rate no faster than 0.5°C every 2 h. This reduces the risk of cerebral hyperperfusion, vasogenic edema, and acute systemic hypotension [102].

During PCAC, a temperature >37.5°C should be avoided and aggressively

There was data suggesting that earlier timing of hypothermia was associated with better outcomes. Moler and colleagues developed a trial to investigate if shorter time to goal temperature was associated with improved outcomes at 1 year. Using data from the Therapeutic Hypothermia After Pediatric Cardiac Arrest Outof-Hosptial Trial (ThAPCA –OH), critically ill children from 38 pediatric intensive care units in the United States and Canada were randomized to therapeutic hypothermia or normothermia [109]. Median time to goal temperature in group 1 was 5.8 h and in group 2 was 8.8 h. However, outcomes between the groups did not differ. They concluded that earlier time to goal temperature was not associated with

Similarly, to other critically ill children, children with PCAS will likely require treatment with sedatives, analgesics, and possibly neuromuscular blockade. There is insufficient data to describe optimal management of sedation and analgesia for pediatric patients with PCAS. With the use of TTM sedation, analgesia and neuromuscular blockade may be used to facilitate cooling and prevent shivering. Caution is advised when using neuromuscular blockade as this will hinder the clinical neu-

be reflected in the minute ventilation [106].

*Sudden Cardiac Death*

treated [108].

better outcomes [110].

rologic exam and will mask seizures.

**4.5 Sedation**

**38**

**4.4 Targeted temperature management (TTM)**

Continuous EEG monitoring for pediatric patients who are encephalopathic following cardiac arrest and ROSC is recommended. This recommendation came forth from the recent consensus statement from the American Clinical Neurophysiology Society Critical Care Continuous EEG Guidelines Committee [111]. It is recommended that EEG monitoring be initiated as soon as possible and continue for 24–48 h. The recommendation also advises to continue monitoring for 24 h after patients treated with hypothermia are rewarmed to normothermia. There have not been studies to evaluate the effect of treatment of seizures in the post-cardiac arrest period on patient outcomes. Generally, most clinicians treat seizures as they can increase metabolic demand and contribute to secondary brain injury.
