**3. Pediatric ECPR**

**1.2 Summary**

*Sudden Cardiac Death*

standpoint.

**2. Medications used in cardiac arrest**

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

The 2015 PALS guidelines discussed three drugs used during resuscitation in children: epinephrine, amiodarone, and lidocaine [24]. **Table 2** highlights these medications, comparing recommendations from the 2015 PALS update and most recent literature that has been published since then. The 2015 PALS guidelines state that it is reasonable to use epinephrine during cardiac arrest. This guideline was based on two pediatric observational studies that were inconclusive and one adult study showing increased ROSC and survival to admission but no change in SHD [24]. Since the 2015 guidelines, an analysis of nonshockable pediatric cardiac arrests in the GWTG registry showed a delay in epinephrine administration was associated with decreased likelihood of survival to admission, ROSC, SHD, and survival with FNO [38]. Another GWTG analysis looked at the intervals between epinephrine administration. Guidelines currently state to give epinephrine every 3–5 min during CPR. This study showed that compared to intervals of 1–5 min as the reference, longer intervals were associated with improved SHD [39]. For shock refractory VF or pulseless VT, the 2015 guidelines changed to state that either amiodarone or lidocaine was acceptable. Previous guidelines had recommended amiodarone as the preferred drug over lidocaine. This is based on pediatric retrospective data that shows lidocaine is associated with improved ROSC and 24-h survival; however, there is no change in SHD [24]. The 2018 update to the PALS guidelines continued

**Medication 2015 PALS guidelines Most recent literature**

*Medications used during pediatric cardiac arrest: Current guidelines vs. most recent literature.*

1. Delay in epinephrine

worse outcomes 2. Longer intervals between epinephrine are associated with

better outcomes

2018 PALS update: no change

administration associated with

Epinephrine It is reasonable to give epinephrine at intervals

Either amiodarone or lidocaine is equally acceptable for shock refractory VF or pulseless

every 3–5 min

VT

Amiodarone/ lidocaine

**Table 2.**

**32**
