*1.1.1.4 Ventilation*

AHA guidelines of 100 to <120, higher rate categories were associated with lower systolic (SBP); however, there was no correlation to survival. Also when compared to the AHA guidelines of 100 to <120, a CC rate of 80 to <100 was associated with a higher rate of SHD and survival with favorable neurological outcome (FNO)

The 2015 update to AHA guidelines recommend to compress at least 1/3 of the anterior–posterior (AP) diameter of the chest, which is about 4 cm in infants, 5 cm in children, and greater than 5 cm but no more than 6 cm in adolescents [4]. Two single-center pediatric studies were reviewed for the 2015 update to the AHA guidelines. The first study was a case series of six infants after cardiac surgery who had CPR. In those infants, aged 0–7 months, attempting to compress the chest to ½ the AP diameter increased the SBP significantly compared to attempts to compress the chest to 1/3 the AP diameter [8]. The second study looked at 87 chest compression events in children >1 year and showed that AHA compliant guideline CC depths >51 mm were associated with improved 24-h survival compared to more shallow CC depths [9]. Since the 2015 update, there has been only one study published. This was a multicenter prospective observational study that looked at out-of-hospital cardiac arrests (OHCA). They looked at 153 pediatric events (children 1–19 years of age) with CPR metric data and found that there was no associa-

tion with CC depth and return of spontaneous circulation (ROSC) [10].

The 2015 AHA guidelines continue to emphasize minimizing interruptions in chest compressions, in particular to less than 10 s. Ideally, these pauses should be coordinated so that a pulse check, rhythm check, and compressor switch occur at the same time and should only occur every 2 min. There should be a person assigned to the role of the pulse check, positioned with his/her finger on the pulse before the pause to minimize the pause duration. Chest compression fraction is defined as the time spent doing chest compressions during CPR. The 2013 AHA consensus statement on CPR quality recommended a CCF of at least 80% [11]; however, the 2015 AHA BLS guidelines recommend a CCF of at least 60% [12]. Observational studies of cardiac arrests often show that pauses can be more prolonged and more frequent than expected. In a single-center observational study in a pediatric emergency room, 33 cardiac arrests were analyzed. While the majority of pauses were <10 s in duration, 33% of pauses were >10 s. The number of coordinated pauses were rare, only 7% of the time [13]. A more recent observational study of CPR quality in two pediatric emergency departments analyzed 81 cardiac arrests. While median CCF was 91% with a median pause duration of 4 s, 22% of pauses were prolonged (>10 s). Again, the number of coordinated pauses were rare (6%) and prolonged with a median of 19 s [14]. Although the AHA guidelines recommend to switch providers performing CC every 2 min to prevent rescuer fatigue and therefore inadequate CPR quality, they also acknowledge that when a CPR feedback device is used, some individuals can go longer than 2 min [15]. A single-center observational study that sought to characterize causes for interruptions found that provider switch accounted for the majority of pauses. Individuals performing CC for at least 120 s compared to those switching earlier had less leaning, increased CC depth, and better compliance for depth with AHA guidelines [16]. While there is limited evidence in adults to support these guidelines on duration of pauses and CCF, these recommendations have been applied to children. There are no pediatric studies to

*1.1.1.3 Minimizing interruptions in chest compressions*

compared to CC rates within guidelines [7].

*1.1.1.2 Chest compression depth*

*Sudden Cardiac Death*

**28**

For patients without an invasive airway at the time of cardiac arrest, BLS guidelines recommend a compression to ventilation ratio of 15:2 in children if there are two providers (in contrast to 30:2 for adults). Although there is no data to support the optimal compression to ventilation ratio in children, the recommended ventilation rate takes into account a higher baseline respiratory rate in children. For children without advanced airways in place at the time of arrest, there is often an emphasis on tracheal intubation during an IHCA given the most common etiology of IHCA is respiratory failure. The 2019 focused update on PALS reaffirms the 2010 recommendation that during a pediatric OHCA, the use of bag mask ventilation (BMV) is reasonable compared to an advanced airway. The update also specifies that no recommendation for or against an advanced airway could be made. These recommendations were made based on the review of 14 studies of airway interventions in children who had cardiac arrests [18].

In contrast to the recommendation for a higher ventilation rate without an advanced airway, when an advanced airway is in place, AHA guidelines recommend that ventilation rates of 10 breaths/min be applied to all age groups during CPR in order to simplify training. During CPR, cardiac output is usually about 25% of normal, and thus lower ventilation rates are recommended to match the lower output state, given the detrimental effects of positive pressure ventilation on venous return and right heart afterload. However, the etiology of cardiac arrest in children is usually asphyxia in nature compared to the primary cardiac origin of most adult cardiac arrests, and thus the recommendations of equal ventilation rates in children as to adults have been questioned. In 2019, the CCPCRN published the only study to date that has analyzed the association of ventilation rates in pediatric cardiac arrests and survival outcomes. As part of the PICqCPR study, the authors analyzed 52 events in patients with an invasive airway in place at the time of the cardiac arrest. No events were within the guideline ventilation rate (defined as 10 2 breaths/min), and more than half of the events were considered high ventilation rates (defined as > or equal to 30 breath/min in infants <1 year and > or equal to 25 in children >1 year). In fact, higher ventilation rates were associated with higher odds of SHD [19].

#### *1.1.1.5 Duty cycle*

The term "duty cycle" refers to the amount of time spent in the compression phase of CPR. AHA guidelines for adult cardiac arrest recommend a duty cycle of 50% [20]. There have been no pediatric recommendations since 2005 on duty cycle. The only pediatric study to date on duty cycle was published in 2016. It was a single-center observational study that analyzed 97 pediatric events and found no association with duty cycle and survival [21].

#### *1.1.1.6 Chest recoil*

AHA guidelines recommend full chest recoil in between compressions, to avoid leaning. In 2009, a single-center prospective observational study sought to evaluate the prevalence of leaning and the effect of real-time feedback devices on leaning. They evaluated 20 pediatric cardiac arrests and found that leaning was common during pediatric CPR; however, leaning occurred significantly less when a feedback device was used [22]. In 2013, the same pediatric center published another prospective observational study looking at the quality of CPR in children 1–8 years of age with a real-time feedback device. In eight events, they found the percentage of CPR epochs (defined as 30-s periods of resuscitation) achieving the target goal of leaning <20% of compressions was 79%. In particular, the percent epochs achieving target leaning goals was better in the feedback group than in the no feedback device [23]. There are no studies to date evaluating the association with leaning and outcomes in children.

Statement on CPR quality recommends titrating CoPP to >20 mm Hg in adults if invasive arterial line and central venous catheter is in place, they state that there is insufficient evidence to make a CoPP goal for infants and children [11]. While no pediatric studies exist, one pediatric animal study showed improvement in a hemodynamic-directed approach to CPR. In a study with 4-week-old piglets, hemodynamic-directed CPR with compression depth titrated to SBP > 90 mm Hg and vasopressor administration to maintain CPP ≥ 20 mm Hg resulted in higher

The 2015 AHA guidelines state that it is reasonable to use audiovisual feedback devices during CPR to optimize CPR quality. As mentioned before, there have been studies showing improvement in pediatric CPR quality with the addition of a realtime CPR feedback device [22, 23]. However, a systematic review and meta-analysis of studies using real-time feedback devices has not shown improvement in patient

While mechanical chest compression devices such as Autopulse and LUCAS have been used in adults, both devices are not intended for use in children [31, 32].

There have been multiple adult studies showing that the implementation of a debriefing program can lead to improved CPR quality and outcomes [33]. There are generally two approaches to debriefing, hot debriefs and cold debriefs. Hot debriefs occur usually within hours after a cardiac arrest with team members involved in the cardiac arrest and involve mainly the members' recall of the events and their immediate reactions. Cold debriefs occur at a later time, within weeks of an event with a larger audience that includes the immediate team members but also other ICU staff. The cold debrief involves a more comprehensive review of the cardiac arrest and can include more objective measures such as defibrillator CPR data and physiologic monitor data [34]. Pediatric studies on debriefings have been limited. A study of the content and process of hot debriefs from the pediRES-Q collaborative revealed approximately half of all cardiac arrests are followed by hot debriefs. The content of the hot debriefs are usually about cooperation/coordination, communication, and clinical standards [35]. The association between hot debriefs and outcomes still needs to be determined. A single-center prospective interventional study sought to evaluate the effectiveness of the implementation of a cold

debriefing program on survival outcomes in children. They found that implementation of their program was associated with improved CPR quality and survival with

Despite excellent quality CPR, many clinicians question whether continuing resuscitation is futile for prolonged cardiac arrests. An analysis of the GWTG registry aimed to examine the effect of CPR duration for pediatric IHCA on outcomes. The authors concluded that CPR duration was independently associated with SHD and survival with FNO. However, among survivors, survival with FNO was 70% in those arrests occurring <15 min and 60% for those patients with arrests >35 min. Compared to medical patients, surgical cardiac patients had the highest

adjusted OR for SHD and survival with FNO [37].

survival rate than standard care of CC depth 1/3 AP diameter [29].

*1.1.3 CPR devices*

*Pediatric Cardiac Arrest*

*DOI: http://dx.doi.org/10.5772/intechopen.92381*

outcomes [30].

*1.1.4 Debriefing*

FNO [36].

**31**

*1.1.5 CPR duration*

#### *1.1.2 Physiologic monitoring*
