2019 American Heart Association

Focused Update on Pediatric Advanced

Life Support: An Update to the
American Heart Association Guidelines
for Cardiopulmonary Resuscitation and
Emergency Cardiovascular Care
Jonathan P. Duff, MD, MEd, Chair; Alexis A. Topjian, MD, MSCE, FAHA; Marc D. Berg, MD; Melissa Chan, MD; Sarah E. Haskell, DO;
Benny L. Joyner, Jr, MD, MPH; Javier J. Lasa, MD; S. Jill Ley, RN, MS, CNS; Tia T. Raymond, MD, FAHA;
Robert Michael Sutton, MD, MSCE; Mary Fran Hazinski, RN, MSN, FAHA; Dianne L. Atkins, MD, FAHA

This 2019 focused update to the American Heart Association pediatric abstract
advanced life support guidelines follows the 2018 and 2019 systematic
reviews performed by the Pediatric Life Support Task Force of the
International Liaison Committee on Resuscitation. It aligns with the
continuous evidence review process of the International Liaison Committee
on Resuscitation, with updates published when the International Liaison
Committee on Resuscitation completes a literature review based on new
published evidence. This update provides the evidence review and treatment
recommendations for advanced airway management in pediatric cardiac
arrest, extracorporeal cardiopulmonary resuscitation in pediatric cardiac
arrest, and pediatric targeted temperature management during post–cardiac
arrest care. The writing group analyzed the systematic reviews and the
original research published for each of these topics. For airway management,
the writing group concluded that it is reasonable to continue bag-mask Key Words: advanced cardiac life support n airway
ventilation (versus attempting an advanced airway such as endotracheal management n cardiopulmonary resuscitation n
intubation) in patients with out-of-hospital cardiac arrest. When extracorporeal membrane oxygenation n heart
arrest n hypothermia, induced n pediatrics
extracorporeal membrane oxygenation protocols and teams are readily
available, extracorporeal cardiopulmonary resuscitation should be considered The American Heart Association and the American
for patients with cardiac diagnoses and in-hospital cardiac arrest. Finally, it Academy of Pediatrics make every effort to avoid any
actual or potential conflicts of interest that may
is reasonable to use targeted temperature management of 32°C to 34°C
arise as a result of an outside relationship or
followed by 36°C to 37.5°C, or to use targeted temperature management of a personal, professional, or business interest of
36°C to 37.5°C, for pediatric patients who remain comatose after resuscitation a member of the writing panel. Specifically, all
from out-of-hospital cardiac arrest or in-hospital cardiac arrest. members of the writing group are required to
complete and submit a Disclosure Questionnaire
showing all such relationships that might be
perceived as real or potential conflicts of interest.

This 2019 focused update to the “2019 International Consensus on

To cite: Duff JP, Topjian AA, Berg MD, et al. 2019
American Heart Association (AHA) Cardiopulmonary Resuscitation American Heart Association Focused Update on
pediatric advanced life support (PALS) and Emergency Cardiovascular Pediatric Advanced Life Support: An Update to
guidelines for cardiopulmonary Care Science With Treatment the American Heart Association Guidelines for
resuscitation (CPR) and emergency Recommendations” (CoSTR) from Cardiopulmonary Resuscitation and Emergency
Cardiovascular Care. Pediatrics. 2020;145(1):
cardiovascular care (ECC) is based on 3 the Pediatric Life Support Task Force
e20191361
systematic reviews1–3 and the resulting of the International Liaison Committee

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PEDIATRICS Volume 145, number 1, January 2020:e20191361 SPECIAL ARTICLE
on Resuscitation (ILCOR).4 This Evidence according to the Although endotracheal intubation can
pediatric life support task force nomenclature developed by the partially mitigate the risk of
CoSTR addressed 3 topics: advanced American College of Cardiology/AHA aspiration and enables delivery of
airway management in pediatric recommendations for developing uninterrupted chest compressions, it
cardiac arrest, extracorporeal CPR clinical practice guidelines (Table)9 requires specialized equipment and
(ECPR) in pediatric cardiac arrest, by using the process detailed in skilled providers. Pediatric airway
and pediatric targeted temperature the “2015 American Heart anatomy differs from that of adults,
management (TTM) during Association Guidelines Update for so tracheal intubation may be more
post–cardiac arrest care. The draft Cardiopulmonary Resuscitation and difficult for healthcare professionals
pediatric CoSTRs were posted online Emergency Cardiovascular Care.”10 who do not routinely intubate
for public comment,5–7 and It is importantto note that this 2019 pediatric patients. A supraglottic
a summary document containing the focused update to the AHA PALS airway (SGA) such as the laryngeal
final CoSTR wording has been guidelines re-evaluates only the mask airway may be easier to place
published simultaneously with this recommendations for the use of than an endotracheal tube, but it does
focused update.4 advanced airway management during not provide a definitive airway and
cardiac arrest, the use of ECPR during does not mitigate the risk of
AHA guidelines for CPR and ECC are
cardiac arrest, and the use of TTM aspiration.
developed in concert with ILCOR’s
systematic review process. In 2015, after cardiac arrest. All other
Evidence Summary—Updated 2019
the ILCOR evidence evaluation recommendations and algorithms
process and the AHA development of published in “Part 12: Pediatric The 2019 ILCOR Pediatric Life
guidelines updates transitioned to Advanced Life Support” in the 2015 Support Task Force and the AHA
a continuous, simultaneous process, AHA guidelines update11 and “Part pediatric writing group reviewed 14
with systematic reviews performed as 14: Pediatric Advanced Life Support” studies of advanced airway
new published evidence warrants or in the “2010 American Heart interventions in pediatric patients
when the ILCOR Pediatric Life Association Guidelines for with cardiac arrest. This included
Support Task Force prioritizes Cardiopulmonary Resuscitation and a clinical trial,17 3 propensity-
a topic. The AHA science experts Emergency Cardiovascular Care”12 adjusted studies,18–20 8 retrospective
review the new evidence and update remain the official recommendations cohort studies,21–28 and 2
the AHA’s guidelines for CPR and ECC of the AHA ECC Science retrospective studies.29,30 The review
as needed, typically on an annual Subcommittee and writing groups. included evidence for the use of an
basis. A description of the evidence The other recommendations advanced airway (endotracheal
review process is available in the contained in the 2017 and 2018 intubation or SGA) versus BMV only.4
2017 ILCOR summary.8 focused updates to the AHA’s This topic was last reviewed in
pediatric basic and advanced life 2010,12 and the previous review did
The ILCOR systematic review support guidelines continue to apply not directly compare outcomes
process uses the Grading of to care delivered to pediatric patients associated with these 3 modalities.
Recommendations Assessment, in cardiac arrest.13,14
Development, and Evaluation Endotracheal Intubation Compared With
methodology and its associated BMV
nomenclature to determine the ADVANCED AIRWAY INTERVENTIONS IN
PEDIATRIC CARDIAC ARREST All 14 studies in the systematic
strength of recommendation and
review examined the outcomes of
certainty of effect for the CoSTR. The Most pediatric cardiac arrests are
endotracheal intubation versus BMV
expert writing group for this 2019 triggered by respiratory
during pediatric cardiac arrest. The
PALS focused update analyzed and deterioration.15,16 As a result, airway
only clinical trial in the review
discussed the original studies and management and ventilation
randomized pediatric patients with
carefully considered the ILCOR management are fundamental
out-of-hospital cardiac arrest (OHCA)
Pediatric Life Support Task Force components of PALS. A number of
to either BMV alone or BMV followed
consensus recommendations4 in light options exist for airway management
by endotracheal intubation.17 There
of the structure and resources of in pediatric cardiac arrest. Although
was no significant difference between
the out-of-hospital and in-hospital the majority of pediatric patients can
the groups in favorable neurologic
resuscitation systems and providers be successfully ventilated with bag-
outcome or survival to hospital
who use AHA guidelines. In mask ventilation (BMV), this method
discharge.
addition, the writing group came to requires interruptions in chest
a consensus about the Classes of compressions and is associated with Two propensity-adjusted studies
Recommendation and Levels of risk of aspiration and barotrauma. were included in the review. In

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2 DUFF et al
a database study from the Get With were compared, neither was reaffirms the 2010 recommendation
The Guidelines–Resuscitation associated with significant with no significant changes. In
registry, endotracheal intubation improvement in survival to hospital addition, we highlight the evidence
during in-hospital cardiac arrest admission. However, 1 cohort study associated with the use of specific
(IHCA) was associated with found improved survival associated types of airway intervention,
decreased survival to hospital with endotracheal intubation endotracheal intubation and SGAs,
discharge.18 A review from an compared with SGA.28 comparing their effects with those of
American cardiac arrest registry, BMV. The evidence for this
CARES (American Cardiac Arrest Additional Considerations recommendation was largely from
Registry to Enhance Survival), of The pediatric ILCOR CoSTR authors observational studies, so reported
pediatric patients with OHCA attempted to conduct a subgroup findings must be interpreted as
comparing outcomes of patients analysis to compare outcomes of associated with, rather than caused
treated with BMV and those treated pediatric IHCA and OHCA, as well as by, the intervention. However, the
with endotracheal intubation found traumatic versus medical causes of writing group agreed that a Class 2a
an association between BMV and arrest. Outcomes from IHCA and recommendation was appropriate.
more than double the rate of survival OHCA were similar. However, very When used by providers with proper
to hospital discharge (odds ratio, 2.56 few studies focused on IHCA; these experience and training, BMV was not
[95% CI, 1.69–3.85]).19 included 1 propensity-matched associated with inferior outcomes
cohort study18 and 2 other cohort compared with endotracheal
SGA Placement Compared With BMV studies.23,27 Outcomes of traumatic intubation or SGA; thus, BMV is
Alone a reasonable alternative to these
and nontraumatic arrest could not be
Four observational studies were compared because published studies advanced airways, which may require
identified in the 2019 ILCOR included only a small number of more specific training or equipment.
systematic review of pediatric SGA patients identified as having During OHCA, transport time,
versus BMV. All were focused on traumatic arrest. provider skill level and experience,
patients with OHCA. Two presented and equipment availability should be
propensity-adjusted cohort data,19,20 Recommendation—Updated 2019 considered in the selection of the
and 2 provided simple observational 1. BMV is reasonable compared most appropriate airway
data.26,28 In the 2 propensity-adjusted with advanced airway intervention. If BMV is ineffective
reviews, from the All-Japan Utstein interventions (endotracheal despite appropriate optimization,
Registry20 and CARES,19 comparing intubation or SGA) in the more advanced airway interventions
outcomes of SGA versus BMV, management of children during should be considered.
there was no association between cardiac arrest in the out-of-
the use of SGA and increased The writing group determined that
hospital setting (Class 2a; Level
favorable neurologic outcome. there was insufficient evidence to
of Evidence C-LD).
In 2 non–propensity-matched make any recommendation about
observational studies comparing the We cannot make a recommendation advanced airway management for
use of SGA with BMV,26,28 the SGA was for or against the use of an advanced IHCA and could not determine
associated with a significant increase airway for IHCA management. In whether either endotracheal
in survival to hospital discharge and addition, no recommendation can be intubation or SGA was superior in
return of spontaneous circulation. made about which advanced airway either setting.
intervention is superior in either
SGA Placement Compared With OHCA or IHCA.
Endotracheal Intubation ECPR FOR IHCA
Four observational studies (2 were Discussion The use of extracorporeal membrane
propensity adjusted) also compared The use of advanced airways in oxygenation (ECMO) as a form of
endotracheal intubation with SGA in pediatric cardiac arrest was last mechanical circulatory rescue for
pediatric patients with OHCA. When reviewed by ILCOR in 2010, with the failed conventional CPR (ie, ECPR)
compared, neither SGA nor following recommendation: “In the has gained popularity since its first
endotracheal intubation was prehospital setting it is reasonable to use as a form of postcardiotomy
associated with a significant increase ventilate and oxygenate infants and rescue in children after surgery for
or decrease in favorable neurologic children with a bag-mask device, congenital heart disease.31,32 ECPR is
outcome or survival to hospital especially if transport time is short defined as the rapid deployment of
discharge.19,20,26,28 Similarly, when (Class IIa, LOE [Level of Evidence] venoarterial ECMO during active CPR
SGA and endotracheal intubation B).”12 This 2019 focused update or for patients with intermittent

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PEDIATRICS Volume 145, number 1, January 2020 3
Table Applying Class of Recommendation and Level of Evidence to Clinical Strategies, Interventions, Treatments, or Diagnostic Testing in Patient Care
(Updated August 2015)*

return of spontaneous circulation. causes.33 ECPR use rates have the use of ECPR in pediatric cardiac
ECPR is a resource-intense, complex increased, with single-center reports arrest. The first study was
multidisciplinary therapy that in both adults and children a retrospective review (2000–2008)
traditionally has been limited to large suggesting that application of this of the Get With The
academic medical centers with therapy across broader patient Guidelines–Resuscitation registry of
providers who have expertise in the populations may improve survival pediatric patients with IHCA after
management of children with cardiac after both OHCA and IHCA.34–36 cardiac surgery.37 On adjusted
disease. Judicious use of ECPR for multivariate analysis, the use of ECPR
specialized patient populations and Evidence Summary—Updated 2019 was associated with higher rates of
within dedicated and highly practiced The ILCOR Pediatric Life Support survival to hospital discharge than
environments has proved successful, Task Force and the AHA pediatric conventional CPR. A second review of
especially for IHCA with reversible writing group reviewed 3 studies on the same database used a propensity

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4 DUFF et al
 Disclosures
Writing Group Disclosures
Writing Employment Research Other Speakers’ Expert Ownership Consultant/Advisory Other
Group Grant Research Bureau/ Witness Interest Board
Member Support Honoraria
Jonathan P. University of Alberta and None None None None None None None
Duff Stollery Children’s Hospital
(Canada)
Dianne L. University of Iowa None None None None None None None
Atkins
Marc D. Berg Stanford University None None None None None None None
Melissa BC Children’s Hospital (Canada) None None None None None None None
Chan

PEDIATRICS Volume 145, number 1, January 2020

Sarah E. University of Iowa NIH (K08 Career Development in Zebrafish Cardiac None None None None None None
Haskell Development)*
Mary Fran Vanderbilt University School of None None None None None American Heart Association None
Hazinski Nursing Emergency
Cardiovascular Care
Programs†
Benny L. University of North Carolina None None None None None None None
Joyner Jr
Javier Texas Children’s Hospital, Baylor None None None None None None None
J. Lasa College of Medicine
S. Jill Ley American Association of Critical None None None None None None None
Care Nurses
Tia T. Medical City Children’s Hospital NIH R01 (Optimized and Personalized Ventilation to Improve None None None None None None
Raymond Pediatric Cardiac Arrest Outcomes [OPTI-VENT] [Studies
in Neonatal and Pediatric Resuscitation])*; NIH R03 (The
Impact on Outcomes of Emergency Medications at the
Bedside in Pediatric Cardiac ICU Patients)*
Robert The Children’s Hospital of NHLBI (PI on CPR Quality Improvement trial)* None None Roberts and Durkee†; None None None
Michael Philadelphia, University Lowis and Gellen*;
Sutton of Pennsylvania School Donahue, Durham,
of Medicine and Noonan*
Alexis A. The Children’s Hospital of NIH (subaward)* None None Plaintiff* None None None
Topjian Philadelphia, University
of Pennsylvania School

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of Medicine
This table represents the relationships of writing group members that may be perceived as actual or reasonably perceived conflicts of interest as reported on the Disclosure Questionnaire, which all members of the writing group are required to
complete and submit. A relationship is considered to be “significant” if (a) the person receives $10 000 or more during any 12-mo period, or 5% or more of the person’s gross income; or (b) the person owns 5% or more of the voting stock or
share of the entity, or owns $10 000 or more of the fair market value of the entity. A relationship is considered to be “modest” if it is less than “significant” under the preceding definition.
* Modest.
† Significant.

5
 analysis to examine the association of

This table represents the relationships of reviewers that may be perceived as actual or reasonably perceived conflicts of interest as reported on the Disclosure Questionnaire, which all reviewers are required to complete and submit. A
relationship is considered to be “significant” if (a) the person receives $10 000 or more during any 12-mo period, or 5% or more of the person’s gross income; or (b) the person owns 5% or more of the voting stock or share of the entity, or owns
Other

None

None

None

None

None

None
ECPR with favorable neurologic
outcome in patients with IHCA of any
origin.38 During an 11-year period
Consultant/
Advisory
Board

(January 2000–December 2011),

3756 patients were enrolled, with
None

None

None

None

None

None
591 receiving ECPR. Compared with
conventional CPR, the use of ECPR
Expert Ownership
Witness Interest

was associated with higher favorable

None

None

None

None

None

None
neurologic outcome at hospital
discharge (odds ratio, 1.78 [95% CI,
1.31–2.41]).
None

None

None

None

None

None

A third study was a single-center

retrospective review of patients with
Honoraria
Speakers’
Bureau/

congenital heart disease who

experienced cardiac arrest during
None

None

None

None

None

None

cardiac catheterization.39 During

Research
Support

a total of 7289 cardiac catheterization

Other

$10 000 or more of the fair market value of the entity. A relationship is considered to be “modest” if it is less than “significant” under the preceding definition.
None

None

None

None

None

AHRQ (PI on a K08 from AHRQ studying prediction and diagnosis of pediatric septic shock. I do None

procedures, 70 infants and children

had cardiac arrest; of these, 18 (26%)
received ECPR. The use of ECPR was
associated with worse survival to
hospital discharge compared with
conventional CPR, although there was
no adjustment for potential
confounding variables.
The pediatric ILCOR systematic
review and CoSTR4,6 found no
published studies reporting the
not directly receive personal funds from the grant.)*

outcomes after the application of

Research

ECPR for pediatric OHCA.

Grant

Recommendation—Updated 2019
1. ECPR may be considered for
pediatric patients with cardiac
diagnoses who have IHCA in
settings with existing ECMO
protocols, expertise, and
equipment (Class 2b; Level of
Evidence C-LD).
There is insufficient evidence to
recommend for or against the use of
None

None

None

None

None

ECPR for pediatric patients

experiencing OHCA or for pediatric
Lurie Children’s Heart

Halden F. Scott Children’s Hospital

patients with noncardiac disease

University of New
Employment

Johns Hopkins

experiencing IHCA refractory to

Washington

Tennessee
University of

University of
University

Colorado

conventional CPR.
Mexico

Center
Reviewer Disclosures

Discussion
The 2015 AHA PALS guidelines
Mark Meredith

suggested that ECPR “be considered

Elizabeth A.
Diekema

McBride
Greene

Jeffers

* Significant.
Justin M.
Reviewer

for pediatric patients with cardiac

Douglas

Mary E.

diagnoses who have IHCA in settings

with existing ECMO protocols,

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6 DUFF et al
expertise, and equipment (Class IIb, 12 months of age.51 In patients who Evidence Summary—Updated 2019
LOE [Level of Evidence] C-LD).”11 received ECPR, therapeutic The 2019 ILCOR pediatric CoSTR
There were no prospective hypothermia, compared with summarized the evidence supporting
comparative analyses comparing normothermia, tended to be associated the use of TTM (32°C–34°C) after
survival and neurologic outcomes with lower survival with good IHCA or OHCA in infants, children,
between conventional CPR and ECPR. neurobehavioral outcome at 1 year.51 and adolescents ,18 years of age.4,7
This is not surprising given the This pediatric review was triggered
potential ethical and logistical Single-center analyses lack
by the publication of the results of the
challenges in recruiting children for consistency in reported measures of
THAPCA-IH trial (Therapeutic
a prospective randomized trial during neurologic function/status yet
Hypothermia After Pediatric Cardiac
a cardiac arrest. However, data from demonstrate favorable neurologic
Arrest In-Hospital), a randomized
large multicenter registry and outcomes for the majority of
controlled trial of TTM 32°C to 34°C
retrospective propensity score survivors at follow-up (median range,
versus TTM 36°C to 37.5°C for
analyses in child and adult 25–52 months).49,50 Post–cardiac
IHCA.54 Unlike previous ILCOR
populations suggest that ECPR may arrest care for patients undergoing
reviews and several earlier AHA PALS
provide a significant survival benefit ECPR should include ongoing
guidelines, the ILCOR pediatric
when used for refractory cardiac surveillance for neurologic injury
CoSTR4 and this 2019 PALS focused
arrest.38,40,41 Presumably, without through the end of the ECMO course.
update are based only on evidence
ECPR, many of these patients would from pediatric studies; this update
have died as a result of failed did not consider evidence
resuscitation attempts. POST–CARDIAC ARREST TTM
extrapolated from adult studies. The
Current survival to hospital discharge TTM refers to continuous writing group agreed that pediatric
rates for critically ill children maintenance of patient temperature patients receiving TTM after cardiac
experiencing IHCA resuscitated with within a narrowly prescribed range. arrest differ substantially from adult
conventional CPR range from 29% to In initial studies of temperature patients because infants and children
44%.42,43 In contrast, recent ECPR management after cardiac arrest in have different causes of cardiac
studies of pediatric IHCA have adults52 and after hypoxic-ischemic arrest, initial arrest rhythms, and
reported survival to hospital insult in neonates,53 therapeutic techniques and equipment used for
discharge rates for mixed cardiac and hypothermia (32°C–34°C) was TTM, as well as differences in
noncardiac ICU populations as high as compared with standard post–cardiac arrest care, compared
48%.32,44,45 Additional analyses (uncontrolled) temperature with adults.
reported that ECPR in the cardiac ICU management that did not include
fever prevention. In these early The THAPCA-IH trial was a large,
was associated with higher survival
studies, fever in the control group multi-institutional, prospective,
to hospital discharge rates in patients
may have contributed to worse randomized controlled study of
with surgical cardiac disease
outcomes and to the comparatively infants and children 2 days to
compared with patients in the general
higher survival reported in the group 18 years of age. Methods and
ICU setting (73% versus 42%,
treated with hypothermia. More outcomes analyzed were identical to
respectively).46–48 Our understanding
recent studies compared what was the 2015 THAPCA-OH trial
of neurologic function after
described as therapeutic hypothermia (Therapeutic Hypothermia After
resuscitation with ECPR consists of
(32°C–34°C) with controlled Pediatric Cardiac Arrest Out-of-
single-center follow-up analyses49,50
normothermia (36°C–37.5°C), with Hospital).16 Both THAPCA studies
and the results of a randomized
fever actively prevented.16,54 These evaluated the association between
prospective trial of therapeutic
treatment modalities are now temperature targets and outcomes in
hypothermia after IHCA.51
referred to as TTM 32°C to 34°C and children who received chest
There is insufficient information about TTM 36°C to 37.5°C, respectively. compressions for at least 2 minutes,
neurologic complications and outcomes were comatose (motor Glasgow Coma
(ie, hemorrhagic/ischemic stroke, Therapeutic hypothermia treats Scale score ,5), and were dependent
seizure) associated with the use of reperfusion syndrome after cardiac on mechanical ventilation after return
ECPR in infants and children. In arrest by decreasing metabolic of spontaneous circulation; both
a multicenter randomized trial of demand, reducing free radical studies used the same protocol.16,54
therapeutic hypothermia after IHCA, production, and decreasing The only difference between the
only 30.5% of patients who received apoptosis.55 It is not clear whether studies was the location of the arrest
ECPR for IHCA had good TTM to different temperature ranges of the enrolled patients. The primary
neurobehavioral outcomes at has the same impact. outcome evaluated for both trials was

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PEDIATRICS Volume 145, number 1, January 2020 7
favorable neurobehavioral outcome at (20% versus 12%; relative risk, 1.59 within the adult population, the ILCOR
1 year, with secondary outcomes of [95% CI, 0.89–2.85]). There were also Pediatric Life Support Task Force and
survival at 1 year and change in no differences in secondary this writing group placed a higher
neurobehavioral outcome. In both outcomes, including change in value on pediatric data because the
studies, temperature targets were neurobehavioral scores from baseline, adult studies include patients with
actively maintained for 120 hours survival at 28 days, or survival at arrest causes, disease states, and
with the use of anteriorly and 1 year.16 outcomes that differ from those of
posteriorly placed automated cooling children and thus would provide only
blankets. Temperature was Recommendations—Updated 2019 indirect evidence.
continuously and centrally 1. Continuous measurement of
monitored. Patients in the TTM 32°C core temperature during TTM is Although there were no significant
to 34°C group were cooled to a core recommended (Class 1; Level of differences in outcomes between the
temperature of 33°C (range, 32°C–34° Evidence B-NR). 2 TTM groups in the THAPCA trials
C) with neuromuscular blockade and (ie, therapeutic hypothermia versus
sedation for the first 48 hours. They 2. For infants and children therapeutic normothermia),
were then rewarmed over a minimum between 24 hours and 18 years hypothermia has been shown to be
of 16 hours and actively maintained of age who remain comatose advantageous in animal models and
at 36.8°C (range, 36°C–37.5°C) for the after OHCA or IHCA, it is neonatal hypoxic injury and in
remainder of the study. Patients in the reasonable to use either TTM mediating the adverse effects of the
TTM 36°C to 37.5°C cohort received 32°C to 34°C followed by TTM post–cardiac arrest syndrome. Given
identical care except for a targeted 36°C to 37.5°C or to use the severity of neurologic injury that
temperature of 36.8°C (range, 36° TTM 36°C to 37.5°C (Class 2a; many children demonstrate after
C–37.5°C) for the entire 5-day Level of Evidence B-NR). resuscitation from cardiac arrest,
intervention period.16,54 There is insufficient evidence to cardiac arrest poses a substantial
support a recommendation about public health burden, representing
The THAPCA-IH trial was halted for large numbers of years lost, which
treatment duration. The THAPCA
futility after enrollment of 59% of makes potential interventions to
(Therapeutic Hypothermia After
targeted patients because the primary improve neurologic injury and
Pediatric Cardiac Arrest) trials used
outcome (favorable neurobehavioral survival a critical priority.
2 days of TTM 32°C to 34°C followed
outcome at 1 year) did not differ
by 3 days of TTM 36°C to 37.5°C or Although interpretation of many
significantly between the TTM 32°C
used 5 days of TTM 36°C to 37.5°C. studies of pediatric patients
to 34°C (36%, 48 of 133) and TTM
36°C to 37.5°C (39%, 48 of 124; Discussion resuscitated from IHCA or OHCA is
relative risk, 0.92% [95% CI, challenged by low-quality evidence in
Since publication of the 2015 PALS
0.67–1.27]; P = .63) groups. heterogeneous populations, most
guidelines, an additional randomized observational studies have yielded
Secondary outcomes, including
controlled trial of TTM of comatose similar findings.56–59 These studies
a change in neurobehavioral outcome
children after IHCA has been used different control groups, arrest
score by at least 1 SD from prearrest
published.54 This in-hospital study, locations, age groups, causes of
baseline at 1 year (30% versus 29%;
from the same investigational team
P = .70), survival at 28 days (63% arrest, duration of TTM, and type of
and with the same treatment protocol
versus 59%; P = .40), and survival at follow-up. Despite 1 small
as the out-of-hospital study,16
1 year (49% versus 46%; P = .56), did observational study of TTM in OHCA
compared post–cardiac arrest TTM survivors demonstrating statistical
not differ between TTM groups. There
32°C to 34°C with TTM 36°C to 37.5°C. improvement in neurologic
were no significant differences
Together, these trials form the basis recovery59 and an observational
between the temperature groups in
of the current guidelines. Although study of IHCA demonstrating worse
the frequency of adverse events,
several pediatric observational neurologic outcomes and survival
including infection, need for
studies were also included in the after TTM,56 the majority of studies
transfusion, and serious arrhythmias
ILCOR evidence review,7 the
within the first 7 days.54 have demonstrated no differences in
observational studies had differing ICU duration of stay, neurologic
The THAPCA-OH trial analyzed data inclusion and exclusion criteria and outcomes, and mortality with the use
from 260 patients. There was no varying protocols for temperature of therapeutic hypothermia versus
significant difference in the primary management, duration of TTM, and controlled normothermia.
outcome between patients treated definitions of harm.56–59 In addition,
with TTM 32°C to 34°C and those although there are several Both THAPCA trials16,54 and 2
treated with TTM 36°C to 37.5°C randomized controlled trials of TTM observational studies60,61 used active

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8 DUFF et al
normothermia to maintain inherently longer for OHCA, as are the recruitment, especially in the
temperature below the febrile range. times to initiation of CPR, airway randomized trials, occurred over
The other 7 observational management, pharmacological many years, during which
studies56–59,62–64 analyzed in the therapies, and defibrillation. The recommendations for CPR changed,
systematic review3 did not control presence of comorbidities, initial including the recent changes to put
temperature in the control group; rhythms, and arrest causes all differ greater emphasis on CPR quality. The
thus, there was a risk of fever that between children with OHCA and exclusion criteria were extensive and
could have contributed to worse those with IHCA. However, because may have excluded some patients
outcomes in the control group. This the conclusions of the 2 THAPCA who might have benefitted from TTM.
lack of temperature regulation in the trials16,54 were the same, we have Finally, and significantly, across the
control groups is a key limitation and made a merged recommendation for sites, there was no consistent use of
a potential source of bias in these both OHCA and IHCA. a post–cardiac arrest care bundle
studies. Fever is common after The ILCOR pediatric ECPR systematic such as identifying and supporting
a hypoxic-ischemic event such as review included multiple subgroup optimal blood pressure, metabolic or
cardiac arrest and has been shown analyses evaluating the critical oxygen/ventilation targets, and
from registry data to be associated outcomes of favorable methods of supportive care.
with worse outcomes after cardiac neurobehavioral function and
arrest.65 The negative results of In the randomized trials,16,54 the
survival at multiple time points.3 duration of TTM was 120 hours (5
recent TTM trials may be explained These subgroup analyses included
by the active maintenance of days). In the observational trials,
location of arrest (OHCA versus the duration of hypothermia
normothermia in control patients IHCA), presumed cause of arrest
rather than a true noneffect of varied from 24 to 72 hours.56,58–64
(cardiac, asphyxial, drowning), and Similarly, the duration of the
hypothermia. The early trials use of ECMO. Although no subgroup
of hypothermia in both neonates rewarming period varied. Because
analysis was found to favor one no randomized trial tested the
and adults did not prevent fever, treatment over another, the analyses
whereas later trials did.53,66,67 duration of TTM, the writing group
were limited because only 1 felt that there was insufficient
A more recent TTM trial in randomized trial exists for each
neonates receiving ECMO used evidence to make a specific
location, and the small sample sizes recommendation on this important
normothermic temperatures in and lack of conformity within the
the control group and did not aspect of the therapy.
observational trials prevented the
demonstrate differences in pooling of data. Subgroup analyses of Given the uncertainty of the effect
outcomes or adverse effects.68 adverse events, including infection, of TTM, limitations of the data
Whether using TTM 32°C to 34°C serious bleeding, and recurrent analysis, and lack of demonstrable
followed by TTM 36°C to 37.5°C cardiac arrest, were feasible from harm, we agree that it is reasonable
or using TTM 36°C to 37.5°C for only the 2 randomized controlled for clinicians to use TTM to 32°C
infants and children who remain trials. These studies found no to 34°C followed by TTM 36°C to
comatose after return of spontaneous statistical difference in positive 37.5°C or to use TTM 36°C to
circulation, the avoidance of fever outcomes or complications between 37.5°C. Clinicians should
is paramount. TTM 32°C to 34°C and TTM 36°C to consistently implement the
Although these treatment 37.5°C groups in either THAPCA strategy that can most safely
recommendations apply to both trial.16,54 Significant limitations be performed for a specific
OHCA and IHCA, it is important to persist even in the randomized trials, patient in a specific clinical
recognize that outcomes of OHCA and which affects the certainty of any environment. Regardless of
IHCA differ in several key recommendation about TTM during strategy, providers should strive to
determinants. Response intervals are post–cardiac arrest care. Patient prevent fever .37.5°C.

This document was approved by the American Heart Association Science Advisory and Coordinating Committee on July 19, 2019, and the American Heart
Association Executive Committee on August 9, 2019.
The American Heart Association requests that this document be cited as follows: Duff JP, Topjian AA, Berg MD, Chan M, Haskell SE, Joyner BL Jr, Lasa JJ, Ley SJ,
Raymond TT, Sutton RM, Hazinski MF, Atkins DL. 2019 American Heart Association focused update on pediatric advanced life support: an update to the American
Heart Association Guidelines for Cardiopulmonary Resuscitation and Emergency Cardiovascular Care [published online ahead of print November 14, 2019].
Circulation. doi: 10.1161/CIR.0000000000000731

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PEDIATRICS Volume 145, number 1, January 2020 9
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PEDIATRICS Volume 145, number 1, January 2020 13
 2019 American Heart Association Focused Update on Pediatric Advanced Life
Support: An Update to the American Heart Association Guidelines for
Cardiopulmonary Resuscitation and Emergency Cardiovascular Care
Jonathan P. Duff, Alexis A. Topjian, Marc D. Berg, Melissa Chan, Sarah E. Haskell,
Benny L. Joyner Jr, Javier J. Lasa, S. Jill Ley, Tia T. Raymond, Robert Michael
Sutton, Mary Fran Hazinski and Dianne L. Atkins
Pediatrics 2020;145;
DOI: 10.1542/peds.2019-1361 originally published online November 14, 2019;

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 2019 American Heart Association Focused Update on Pediatric Advanced Life
Support: An Update to the American Heart Association Guidelines for
Cardiopulmonary Resuscitation and Emergency Cardiovascular Care
Jonathan P. Duff, Alexis A. Topjian, Marc D. Berg, Melissa Chan, Sarah E. Haskell,
Benny L. Joyner Jr, Javier J. Lasa, S. Jill Ley, Tia T. Raymond, Robert Michael
Sutton, Mary Fran Hazinski and Dianne L. Atkins
Pediatrics 2020;145;
DOI: 10.1542/peds.2019-1361 originally published online November 14, 2019;

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http://pediatrics.aappublications.org/content/145/1/e20191361

Pediatrics is the official journal of the American Academy of Pediatrics. A monthly publication, it
has been published continuously since 1948. Pediatrics is owned, published, and trademarked by
the American Academy of Pediatrics, 345 Park Avenue, Itasca, Illinois, 60143. Copyright © 2020
by the American Academy of Pediatrics. All rights reserved. Print ISSN: 1073-0397.

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