*1.1.2.1 End tidal CO2*

The 2015 PALS guidelines state that it is reasonable to use ETCO2 to guide the quality of CPR in children, although specific values to guide therapy in children have not been established [24]. These recommendations were made on extrapolation of adult and animal data since no pediatric literature at the time of these guidelines had been shown that ETCO2 monitoring improves outcomes. For adults, AHA recommendations are to titrate to an ETCO2 ≥ 20 mm Hg [11]. In 2018, using the PICqCPR data, the CCPCRN published the only pediatric study to date that evaluates the association of ETCO2 values and survival outcomes. Contrary to adult literature, the authors found that there was no association between ETCO2 ≥ 20 mm Hg and SHD [25].

#### *1.1.2.2 Arterial blood pressure*

Similar to the recommendation for ETCO2 monitoring, the 2015 PALS guidelines state that it is reasonable to use BP to guide CPR quality if an invasive arterial line is already in place; however, no specific values to guide therapy have been established [24]. At the time, these recommendations were based on animal data without any pediatric human literature. Since then, the CCPCRN has published three studies using PICqCPR data, evaluating the association of intra-arrest diastolic blood pressure (DBP) and post-arrest outcomes. The first study evaluated 164 events and showed that maintaining a mean DBP ≥ 25 mm Hg in infants and DBP ≥ 30 mm Hg in children was associated with SHD and survival with FNO. There was no association between SBP and outcomes [26]. The second study evaluated 77 survivors of the first study and sought to assess the association between intra-arrest BP and functional outcomes. Unlike the parent study which showed an association between DBP and FNO, there was no association between DBP and functional outcomes. Again, there was no association with SBP and functional outcomes [27]. The third study evaluated the subgroup of patients with cardiac disease. The authors analyzed the hemodynamic waveforms of 113 patients with cardiac disease and found an association with the same DBP goals and SHD in surgical patients but not medical patients. They also noted the majority of patients with single ventricles and open chest were able to attain the DBP goals. In patients who went on to have ECPR, approximately half were able to attain the DBP goals; however, there was no association between DBP goals and SHD [28].

#### *1.1.2.3 Coronary perfusion pressure*

Coronary perfusion pressure (CoPP) can be estimated by subtracting the right atrial (RA) pressure from the aortic DBP. While the 2013 AHA Consensus

#### *Pediatric Cardiac Arrest DOI: http://dx.doi.org/10.5772/intechopen.92381*

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

## *1.1.3 CPR devices*

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 out-

The 2015 PALS guidelines state that it is reasonable to use ETCO2 to guide the quality of CPR in children, although specific values to guide therapy in children have not been established [24]. These recommendations were made on extrapolation of adult and animal data since no pediatric literature at the time of these guidelines had been shown that ETCO2 monitoring improves outcomes. For adults, AHA recommendations are to titrate to an ETCO2 ≥ 20 mm Hg [11]. In 2018, using the PICqCPR data, the CCPCRN published the only pediatric study to date that evaluates the association of ETCO2 values and survival outcomes. Contrary to adult literature, the authors found that there was no association between ETCO2 ≥ 20 mm Hg and SHD [25].

Similar to the recommendation for ETCO2 monitoring, the 2015 PALS guidelines state that it is reasonable to use BP to guide CPR quality if an invasive arterial line is already in place; however, no specific values to guide therapy have been established [24]. At the time, these recommendations were based on animal data without any pediatric human literature. Since then, the CCPCRN has published three studies using PICqCPR data, evaluating the association of intra-arrest diastolic blood pressure (DBP) and post-arrest outcomes. The first study evaluated 164 events and showed that maintaining a mean DBP ≥ 25 mm Hg in infants and DBP ≥ 30 mm Hg in children was associated with SHD and survival with FNO. There was no association between SBP and outcomes [26]. The second study evaluated 77 survivors of the first study and sought to assess the association between intra-arrest BP and functional outcomes. Unlike the parent study which showed an association between DBP and FNO, there was no association between DBP and functional outcomes. Again, there was no association with SBP and functional outcomes [27]. The third study evaluated the subgroup of patients with cardiac disease. The authors analyzed the hemodynamic waveforms of 113 patients with cardiac disease and found an association with the same DBP goals and SHD in surgical patients but not medical patients. They also noted the majority of patients with single ventricles and open chest were able to attain the DBP goals. In patients who went on to have ECPR, approximately half were able to attain the DBP goals; however, there was no association between DBP goals and SHD [28].

Coronary perfusion pressure (CoPP) can be estimated by subtracting the right

atrial (RA) pressure from the aortic DBP. While the 2013 AHA Consensus

comes in children.

*Sudden Cardiac Death*

*1.1.2.1 End tidal CO2*

*1.1.2 Physiologic monitoring*

*1.1.2.2 Arterial blood pressure*

*1.1.2.3 Coronary perfusion pressure*

**30**

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 outcomes [30].

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].

### *1.1.4 Debriefing*

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 FNO [36].

#### *1.1.5 CPR duration*

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].

### **1.2 Summary**

The 2015 AHA guidelines on pediatric CPR are based on extrapolation of evidence from adult and animal studies. Since then there has been a growing amount of literature that supports transitioning CPR from a "provider"-centric to "patient" centric CPR. Recent literature has shown no change or worse outcomes when providers follow "provider"-centric guidelines that use standardized targets. Chest compression rates lower than recommended have been associated with improved outcomes. There has been no association shown between CC depth and outcomes. Ventilation rates higher than 2015 AHA guidelines are associated with improved outcomes. More recent evidence is emerging that demonstrates targeting a patient's physiologic response to CPR may be more beneficial. Evidence has shown that DBP greater than 25 mm Hg in infants and 30 mm Hg in older children are associated with improved outcomes. There are many CPR quality metrics to choose from to guide CPR. These metrics can help improve the quality of CPR from a system-wide standpoint.

to reaffirm the 2015 guidelines. No new pediatric data was available for the updated review; however, the committee did not consider extrapolated adult data [40].

**3.1 History and current use of extracorporeal cardiopulmonary resuscitation**

Extracorporeal membrane oxygenation (ECMO) use for cardiopulmonary resuscitation (CPR) in children was first described in the literature by del Nido in 1992 [41]. Since then, utilization of extracorporeal cardiopulmonary resuscitation has expanded in all pediatric age groups. The current definition of ECPR according to the Extracorporeal Life Support Organization (ELSO) is "the application of rapid-deployment venoarterial ECMO, to provide circulatory support in patients in whom conventional CPR is unsuccessful in achieving sustained return of spontaneous circulation (ROSC). Sustained ROSC is deemed to have occurred when chest compressions are not required for 20 consecutive minutes and signs of circulation persist" [42]. This definition has been used since ELSO updated its data definitions in 2018. Pre-2018, the ELSO definition of ECPR was "ECMO used for initial resuscitation from cardiac arrest" and did not include patients who had achieved ROSC when they were being cannulated for ECMO [43]. Apart from the ELSO definitions, the definition of ECPR varies in clinical studies, and this presents challenges with

Based on ELSO registry data, there has been an increasing use of ECPR in pediatric patients over the years [44]. The overwhelming majority of pediatric ECPR use reported in the literature is for in-hospital cardiac arrest (IHCA) [44]. There are only few reports of ECPR deployed in pediatric patients for out-ofhospital cardiac arrest (OHCA); 2% of pediatric ECPR cases reported to ELSO were for OHCA according to the 2016 pediatric ELSO registry report [44, 45]. There is one case report of out-of-hospital ECMO deployment in a child ("pre-hospital

From reported literature, the incidence of ECPR use varies from 5 to 27% of all pediatric IHCA cases between 2000 and 2016 [37, 47–49]. Of pediatric IHCA cases reported to the American Heart Association (AHA) Get With the Guidelines®- Resuscitation registry between the years 2000 and 2008, the incidence of ECPR use was 5–7% overall and 19–21% in patients with a cardiac diagnosis [37, 47]. More recently, the incidence of ECPR use was 27.2% in cardiac arrest patients reported to the Pediatric Cardiac Critical Care Consortium (PC4) registry between 2014 and

The AHA had not included ECPR in Pediatric Advanced Life Support (PALS) guidelines until 2005 when guidelines were updated to include a consideration of ECPR in patients with a reversible cause of arrest or whose underlying condition could be treated by heart transplantation and who were located at an institution that could rapidly deploy ECMO, where effective conventional CPR had been started promptly [50]. Subsequent PALS updates have included this cautious recommendation to consider ECPR, particularly for cardiac patients with IHCA [18, 24, 51].

Determination of a patient's ECPR candidacy and feasibility of cannulation should preferably be done prior to cardiac arrest. Criteria for determination of candidacy may vary from center to center, and there are no universal guidelines for

**3. Pediatric ECPR**

*Pediatric Cardiac Arrest*

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

ECPR") [46].

2016 [49].

**33**

**(ECPR) in pediatrics**

medical communication and synthesis of research.

**3.2 Cannulation procedure during CPR**
