Part 12: Pediatric Advanced Life Support: 2015 American Heart Association Guidelines Update for Cardiopulmonary Resuscitation and Emergency Cardiovascular Care.

Abstract

HomeCirculationVol. 132, No. 18_suppl_2Part 12: Pediatric Advanced Life Support Free AccessResearch ArticlePDF/EPUBAboutView PDFView EPUBSections ToolsAdd to favoritesDownload citationsTrack citationsPermissions ShareShare onFacebookTwitterLinked InMendeleyReddit Jump toFree AccessResearch ArticlePDF/EPUBPart 12: Pediatric Advanced Life Support2015 American Heart Association Guidelines Update for Cardiopulmonary Resuscitation and Emergency Cardiovascular Care Allan R. de Caen, Marc D. Berg, Leon Chameides, Cheryl K. Gooden, Robert W. Hickey, Halden F. Scott, Robert M. Sutton, Janice A. Tijssen, Alexis Topjian, Élise W. van der Jagt, Stephen M. Schexnayder and Ricardo A. Samson Allan R. de CaenAllan R. de Caen Search for more papers by this author , Marc D. BergMarc D. Berg Search for more papers by this author , Leon ChameidesLeon Chameides Search for more papers by this author , Cheryl K. GoodenCheryl K. Gooden Search for more papers by this author , Robert W. HickeyRobert W. Hickey Search for more papers by this author , Halden F. ScottHalden F. Scott Search for more papers by this author , Robert M. SuttonRobert M. Sutton Search for more papers by this author , Janice A. TijssenJanice A. Tijssen Search for more papers by this author , Alexis TopjianAlexis Topjian Search for more papers by this author , Élise W. van der JagtÉlise W. van der Jagt Search for more papers by this author , Stephen M. SchexnayderStephen M. Schexnayder Search for more papers by this author and Ricardo A. SamsonRicardo A. Samson Search for more papers by this author Originally published3 Nov 2015https://doi.org/10.1161/CIR.0000000000000266Circulation. 2015;132:S526–S542IntroductionOver the past 13 years, survival to discharge from pediatric in-hospital cardiac arrest (IHCA) has markedly improved. From 2001 to 2013, rates of return of spontaneous circulation (ROSC) from IHCA increased significantly from 39% to 77%, and survival to hospital discharge improved from 24% to 36% to 43% (Girotra et al1 and personal communication with Paul Chan, MD, MSc, April 3, 2015). In a single center, implementation of an intensive care unit (ICU)–based interdisciplinary debriefing program improved survival with favorable neurologic outcome from 29% to 50%.2 Furthermore, new data show that prolonged cardiopulmonary resuscitation (CPR) is not futile: 12% of patients receiving CPR in IHCA for more than 35 minutes survived to discharge, and 60% of the survivors had a favorable neurologic outcome.3 This improvement in survival rate from IHCA can be attributed to multiple factors, including emphasis on high-quality CPR and advances in post-resuscitation care. Over the past decade, the percent of cardiac arrests occurring in an ICU setting has increased (87% to 91% in 2000 to 2003 to 94% to 96% in 2004 to 2010).4 While rates of survival from pulseless electrical activity and asystole have increased, there has been no change in survival rates from in-hospital ventricular fibrillation (VF) or pulseless ventricular tachycardia (pVT).Conversely, survival from out-of-hospital cardiac arrest (OHCA) has not improved as dramatically over the past 5 years. Data from 11 US and Canadian hospital emergency medical service systems (the Resuscitation Outcomes Consortium) during 2005 to 2007 showed age-dependent discharge survival rates of 3.3% for infants (less than 1 year), 9.1% for children (1 to 11 years), and 8.9% for adolescents (12 to 19 years).5 More recently published data (through 2012) from this network demonstrate 8.3% survival to hospital discharge across all age groups, with 10.5% survival for children aged 1 to 11 years and 15.8% survival for adolescents aged 12 to 18 years.6Evidence Evaluation Process Informing This Guidelines UpdateThe American Heart Association (AHA) Emergency Cardiovascular Care (ECC) Committee uses a rigorous process to review and analyze the peer-reviewed published scientific evidence supporting the AHA Guidelines for CPR and ECC, including this update. In 2000, the AHA began collaborating with other resuscitation councils throughout the world, via the International Liaison Committee on Resuscitation (ILCOR), in a formal international process to evaluate resuscitation science. This process resulted in the publication of the International Consensus on CPR and ECC Science With Treatment Recommendations (CoSTR) in 2005 and 2010.7,8 These publications provided the scientific support for AHA Guidelines revisions in those years.In 2011, the AHA created an online evidence review process, the Scientific Evidence Evaluation and Review System (SEERS), to support ILCOR systematic reviews for 2015 and beyond. This new process includes the use of Grading of Recommendations Assessment, Development, and Evaluation (GRADE) software to create systematic reviews that will be available online and used by resuscitation councils to develop their guidelines for CPR and ECC. The drafts of the online reviews were posted for public comment, and ongoing reviews will be accessible to the public (https://volunteer.heart.org/apps/pico/Pages/default.aspx).The AHA process for identification and management of potential conflicts of interest was used, and potential conflicts for writing group members are listed at the end of each Part of the 2015 AHA Guidelines Update for CPR and ECC. For additional information about this systematic review or management of the potential conflicts of interest, see “Part 2: Evidence Evaluation and Management of Conflicts of Interest” in this supplement and the related article “Part 2: Evidence Evaluation and Management of Conflict of Interest” in the 2015 CoSTR publication.9,10This update to the 2010 AHA Guidelines for CPR and ECC for pediatric advanced life support (PALS) targets key questions related to pediatric resuscitation. Areas of update were selected by a group of international pediatric resuscitation experts from ILCOR, and the questions encompass resuscitation topics in prearrest care, intra-arrest care, and postresuscitation care. The ILCOR Pediatric Life Support Task Force experts reviewed the topics addressed in the 2010 Guidelines for PALS and, based on in-depth knowledge of new research developments, formulated 18 questions for further systematic evaluation.11 Three questions that address pediatric basic life support appear in “Part 11: Pediatric Basic Life Support and Cardiopulmonary Resuscitation Quality.”Beginning with the publication of the 2015 CoSTR, the ILCOR evidence evaluation process will be continuous, rather than “batched” into 5-year cycles. The goal of this continuous evidence review is to improve survival from cardiac arrest by shortening the time between resuscitation science discoveries and their application in resuscitation practice. As additional resuscitation topics are prioritized and reviewed, these Guidelines may be updated again. When the evidence supports sufficient changes to the Guidelines or a change in sequence or treatments that must be woven throughout the Guidelines, then the Guidelines will be revised completely.Because the 2015 AHA Guidelines Update for CPR and ECC represents the first update to the previous Guidelines, recommendations from both this 2015 Guidelines Update and the 2010 Guidelines are contained in the Appendix. If the 2015 ILCOR review resulted in a new or significantly revised Guidelines recommendation, that recommendation will be labeled as New or Updated.As with all AHA Guidelines, each 2015 recommendation is labeled with a Class of Recommendation (COR) and a Level of Evidence (LOE). This update uses the newest AHA COR and LOE classification system, which contains modifications of the Class III recommendation and introduces LOE B-R (randomized studies) and B-NR (nonrandomized studies) as well as LOE C-LD (limited data) and LOE C-EO (consensus of expert opinion).These PALS recommendations are informed by the rigorous systematic review and consensus recommendations of the ILCOR Pediatric Task Force, and readers are referred to the complete consensus document in the 2015 CoSTR.12,13 In the online version of this document, live links are provided so the reader can connect directly to the systematic reviews on the SEERS website. These links are indicated by a superscript combination of letters and numbers (eg, Peds 397). We encourage readers to use the links and review the evidence and appendixes, including the GRADE tables.This 2015 Guidelines Update for PALS includes science review in the following subjects:Prearrest CareEffectiveness of medical emergency teams or rapid response teams to improve outcomesEffectiveness of a pediatric early warning score (PEWS) to improve outcomesRestrictive volume of isotonic crystalloid for resuscitation from septic shockUse of atropine as a premedication in infants and children requiring emergency tracheal intubationTreatment for infants and children with myocarditis or dilated cardiomyopathy and impending cardiac arrestIntra-arrest CareEffectiveness of extracorporeal membrane oxygenation (ECMO) resuscitation compared to standard resuscitation without ECMOTargeting a specific end-tidal CO2(ETCO2) threshold to improve chest compression techniqueReliability of intra-arrest prognostic factors to predict outcomeUse of invasive hemodynamic monitoring during CPR to titrate to a specific systolic/diastolic blood pressure to improve outcomesEffectiveness of NO vasopressor compared with ANY vasopressors for resuscitation from cardiac arrestUse of amiodarone compared with lidocaine for shock-refractory VF or pVTOptimal energy dose for defibrillationPostarrest CareUse of targeted temperature management to improve outcomesUse of a targeted Pao2strategy to improve outcomesUse of a specific Paco2target to improve outcomesUse of parenteral fluids and inotropes and/or vasopressors to maintain targeted measures of perfusion such as blood pressure to improve outcomesUse of electroencephalograms (EEGs) to accurately predict outcomesUse of any specific post–cardiac arrest factors to accurately predict outcomesPrearrest Care UpdatesMedical Emergency Team/Rapid Response TeamPeds 397Medical emergency team or rapid response team activation by caregivers or parents ideally occurs as a response to changes noted in a patient’s condition and may prevent cardiac or respiratory arrest. Several variables, including the composition of the team, the type of patient, the hospital setting, and the confounder of a wider “system benefit,” further complicate objective analyses.2015 Evidence SummaryObservational data have been contradictory and have not consistently shown a decreased incidence of cardiac and/or respiratory arrest outside of the ICU setting.14–16 The data addressing effects on hospital mortality were inconclusive.16–212015 Recommendation—UpdatedPediatric medical emergency team/rapid response team systems may be considered in facilities where children with high-risk illnesses are cared for on general in-patient units (Class IIb, LOE C-LD).Pediatric Early Warning ScoresPeds 818In-hospital pediatric cardiac or respiratory arrest can potentially be averted by early recognition of and intervention for the deteriorating patient. The use of scoring systems might help to identify such patients sufficiently early so as to enable effective intervention.2015 Evidence SummaryThere is no evidence that the use of PEWS outside of the pediatric ICU setting reduces hospital mortality. In 1 observational study, PEWS use was associated with a reduction in cardiac arrest rate when used in a single hospital with an established medical emergency team system.222015 Recommendation—NewThe use of PEWS may be considered, but its effectiveness in the in-hospital setting is not well established (Class IIb, LOE C-LD).Fluid Resuscitation in Septic ShockPeds 545This update regarding intravenous fluid resuscitation in infants and children in septic shock in all settings addressed 2 specific therapeutic elements: (1) Withholding the use of bolus fluids was compared with the use of bolus fluids, and (2) noncrystalloid was compared with crystalloid fluids.Early and rapid administration of intravenous fluid to reverse decompensated shock, and to prevent progression from compensated to decompensated shock, has been widely accepted based on limited observational studies.23 Mortality from pediatric sepsis has declined in recent years, during which guidelines and publications have emphasized the role of early rapid fluid administration (along with early antibiotic and vasopressor therapy, and careful cardiovascular monitoring) in treating septic shock.24,25 Since the 2010 Guidelines, a large randomized controlled trial of fluid resuscitation in pediatric severe febrile illness in a resource-limited setting found intravenous fluid boluses to be harmful.26 This new information, contradicting long-held beliefs and practices, prompted careful analysis of the effect of fluid resuscitation on many outcomes in specific infectious illnesses.2015 Evidence SummarySpecific infection-related shock states appear to behave differently with respect to fluid bolus therapy. Evidence was not considered to be specific to a particular setting, after determining that “resource-limited setting” is difficult to define and can vary greatly even within individual health systems and small geographic regions.The evidence regarding the impact of restricting fluid boluses during resuscitation on outcomes in pediatric septic shock is summarized in Figure 1. There were no studies for many specific combinations of presenting illness and outcome. In the majority of scenarios, there was no benefit to restricting fluid boluses during resuscitation.Download figureDownload PowerPointFigure 1. Evidence for the use of restrictive volume of intravenous fluid resuscitation, compared with unrestrictive volume, by presenting illness and outcome. Benefit indicates that studies show a benefit to restricting fluid volume, No Benefit indicates that there is no benefit to restricting fluid volume, and Harm indicates that there is harm associated with restricting fluid volume. No Studies Available indicates no studies are available for a particular illness/outcome combination.The most important exception is that in 1 large study, restriction of fluid boluses conveyed a benefit for survival to both 48 hours and 4 weeks after presentation. This study was conducted in sub-Saharan Africa, and inclusion criteria were severe febrile illness complicated by impaired consciousness (prostration or coma), respiratory distress (increased work of breathing), or both, and with impaired perfusion, as evidenced by 1 or more of the following: a capillary refill time of 3 or more seconds, lower limb temperature gradient, weak radial-pulse volume, or severe tachycardia. In this study, administration of 20 mL/kg or 40 mL/kg in the first hour was associated with decreased survival compared with the use of maintenance fluids alone.26 Therefore, it appears that in this specific patient population, where critical care resources including inotropic and mechanical ventilator support were limited, bolus fluid therapy resulted in higher mortality.The use of noncrystalloid fluid was compared with crystalloid fluid for the same diseases and outcomes listed in the preceding paragraph.26–32 Evidence is summarized in Figure 2. In most scenarios, there was no benefit to noncrystalloids over crystalloids. In patients with Dengue shock, a benefit was conferred in using noncrystalloid compared with crystalloid fluid for the outcome of time to resolution of shock.31Download figureDownload PowerPointFigure 2. Evidence for the use of noncrystalloid intravenous fluid resuscitation, compared with crystalloid, by presenting illness and outcome. Benefit indicates that studies show a benefit to the use of noncrystalloid intravenous fluid resuscitation compared with crystalloid, and No Benefit indicates that there is no benefit to the use of noncrystalloid intravenous fluid resuscitation compared with crystalloid. No Studies Available indicates no studies are available for a particular illness/outcome combination.2015 Recommendations—NewAdministration of an initial fluid bolus of 20 mL/kg to infants and children with shock is reasonable, including those with conditions such as severe sepsis (Class IIa, LOE C-LD), severe malaria and Dengue (Class IIb, LOE B-R). When caring for children with severe febrile illness (such as those included in the FEAST trial26) in settings with limited access to critical care resources (ie, mechanical ventilation and inotropic support), administration of bolus intravenous fluids should be undertaken with extreme caution because it may be harmful (Class IIb, LOE B-R). Providers should reassess the patient after every fluid bolus (Class I, LOE C-EO).Either isotonic crystalloids or colloids can be effective as the initial fluid choice for resuscitation (Class IIa, LOE B-R).This recommendation takes into consideration the important work of Maitland et al,26 which found that fluid boluses as part of resuscitation are not safe for all patients in all settings. This study showed that the use of fluid boluses as part of resuscitation increased mortality in a specific population in a resource-limited setting, without access to some critical care interventions such as mechanical ventilation and inotrope support.The spirit of this recommendation is a continued emphasis on fluid resuscitation for both compensated (detected by physical examination) and decompensated (hypotensive) septic shock. Moreover, emphasis is also placed on the use of individualized patient evaluation before the administration of intravenous fluid boluses, including physical examination by a clinician and frequent reassessment to determine the appropriate volume of fluid resuscitation. The clinician should also integrate clinical signs with patient and locality-specific information about prevalent diseases, vulnerabilities (such as severe anemia and malnutrition), and available critical care resources.Atropine for Premedication During Emergency IntubationPeds 821Bradycardia commonly occurs during emergency pediatric intubation, resulting from hypoxia/ischemia, as a vagal response to laryngoscopy, as a reflex response to positive pressure ventilation, or as a pharmacologic effect of some drugs (eg, succinylcholine or fentanyl). Practitioners have often tried to blunt this bradycardia with prophylactic premedication with atropine.2015 Evidence SummaryThe evidence regarding the use of atropine during emergency intubation has largely been observational, including extrapolation from experience with elective intubation in the operating suite. More recent in-hospital literature involves larger case series of critically ill neonates, infants, and children undergoing emergency intubation.33–35There is no evidence that preintubation use of atropine improves survival or prevents cardiac arrest in infants and children. Observational data suggest that it increases the likelihood of survival to ICU discharge in children older than 28 days.33 Evidence is conflicting as to whether preintubation atropine administration reduces the incidence of arrhythmias or postintubation shock.34,35In past Guidelines, a minimum atropine dose of 0.1 mg IV was recommended after a report of paradoxical bradycardia observed in very small infants who received very low atropine doses.36 However, in 2 of the most recent case series cited above, preintubation doses of 0.02 mg/kg, with no minimum dose, were shown to be effective.33,342015 Recommendations—NewThe available evidence does not support the routine use of atropine preintubation of critically ill infants and children. It may be reasonable for practitioners to use atropine as a premedication in specific emergency intubations when there is higher risk of bradycardia (eg, when giving succinylcholine as a neuromuscular blocker to facilitate intubation) (Class IIb, LOE C-LD). A dose of 0.02 mg/kg of atropine with no minimum dose may be considered when atropine is used as a premedication for emergency intubation (Class IIb, LOE C-LD). This new recommendation applies only to the use of atropine as a premedication for infants and children during emergency intubation.Prearrest Care of Infants and Children With Dilated Cardiomyopathy or MyocarditisPeds 819Optimal care of a critically ill infant or child with dilated cardiomyopathy or myocarditis should avert cardiac arrest. While significant global experience exists with the care of these patients, the evidence base is limited. The ILCOR systematic review ultimately restricted its analysis to patients with myocarditis and did not include the use of ventricular assist devices.2015 Evidence SummaryNo literature was identified evaluating best prearrest management strategies (including anesthetic technique) for infants and children with dilated cardiomyopathy or myocarditis. Limited observational data support the pre–cardiac arrest use of ECMO in children with acute fulminant myocarditis.372015 Recommendation—NewVenoarterial ECMO use may be considered in patients with acute fulminant myocarditis who are at high risk of imminent cardiac arrest (Class IIb, LOE C-EO). Optimal outcomes from ECMO are achieved in settings with existing ECMO protocols, expertise, and equipment.Intra-arrest Care UpdatesExtracorporeal CPR for In-Hospital Pediatric Cardiac ArrestPeds 407The 2010 AHA PALS Guidelines suggested the use of ECMO when dealing with pediatric cardiac arrest refractory to conventional interventions and when managing a reversible underlying disease process. Pediatric OHCA was not considered for the 2015 ILCOR systematic review.2015 Evidence SummaryEvidence from 4 observational studies of pediatric IHCA has shown no overall benefit to the use of CPR with ECMO (ECPR) compared to CPR without ECMO.38–41 Observational data from a registry of pediatric IHCA showed improved survival to hospital discharge with the use of ECPR in patients with surgical cardiac diagnoses.42 For children with underlying cardiac disease, when ECPR is initiated in a critical care setting, long-term survival has been reported even after more than 50 minutes of conventional CPR.43 When ECPR is used during cardiac arrest, the outcome for children with underlying cardiac disease is better than for those with noncardiac disease.442015 Recommendation—NewECPR may be considered for pediatric patients with cardiac diagnoses who have IHCA in settings with existing ECMO protocols, expertise, and equipment (Class IIb, LOE C-LD).End-Tidal CO2 Monitoring to Guide CPR QualityPeds 827High-quality CPR is associated with improved outcomes after cardiac arrest. Animal data support a direct association between ETCO2 and cardiac output. Capnography is used during pediatric cardiac arrest to monitor for ROSC as well as CPR quality. The 2010 Guidelines recommended that if the partial pressure of ETCO2 is consistently less than 15 mm Hg, efforts should focus on improving CPR quality, particularly improving chest compressions and ensuring that the victim does not receive excessive ventilation.2015 Evidence SummaryThere is no pediatric evidence that ETCO2 monitoring improves outcomes from cardiac arrest. One pediatric animal study showed that ETCO2-guided chest compressions are as effective as standard chest compressions optimized by marker, video, and verbal feedback for achieving ROSC.45 A recent study in adults found that ETCO2 values generated during CPR were significantly associated with chest compression depth and ventilation rate.462015 Recommendation—NewETCO2 monitoring may be considered to evaluate the quality of chest compressions, but specific values to guide therapy have not been established in children (Class IIb, LOE C-LD).Intra-arrest Prognostic Factors for Cardiac ArrestPeds 814Accurate and reliable prognostication during pediatric cardiac arrest would allow termination of CPR in patients where CPR is futile, while encouraging continued CPR in patients with a potential for good recovery.2015 Evidence SummaryFor infants and children with OHCA, age less than 1 year,5,47 longer durations of cardiac arrest48–50 and presentation with a nonshockable as opposed to a shockable rhythm5,47,49 are all predictors of poor patient outcome. For infants and children with IHCA, negative predictive factors include age greater than 1 year3 and longer durations of cardiac arrest.3,51–53 The evidence is contradictory as to whether a nonshockable (as opposed to shockable) initial cardiac arrest rhythm is a negative predictive factor in the in-hospital setting.3,54,552015 Recommendation—NewMultiple variables should be used when attempting to prognosticate outcomes during cardiac arrest (Class I, LOE C-LD). Although there are factors associated with better or worse outcomes, no single factor studied predicts outcome with sufficient accuracy to recommend termination or continuation of CPR.Invasive Hemodynamic Monitoring During CPRPeds 826Children often have cardiac arrests in settings where invasive hemodynamic monitoring already exists or is rapidly obtained. If a patient has an indwelling arterial catheter, the waveform can be used as feedback to evaluate chest compressions.2015 Evidence SummaryAdjusting chest compression technique to a specific systolic blood pressure target has not been studied in humans. Two randomized controlled animal studies showed increased likelihood of ROSC and survival to completion of experiment with the use of invasive hemodynamic monitoring.56,572015 Recommendation—NewFor patients with invasive hemodynamic monitoring in place at the time of cardiac arrest, it may be reasonable for rescuers to use blood pressure to guide CPR quality (Class IIb, LOE C-EO). Specific target values for blood pressure during CPR have not been established in children.Vasopressors During Cardiac ArrestPeds 424During cardiac arrest, vasopressors are used to restore spontaneous circulation by optimizing coronary perfusion and to help maintain cerebral perfusion. However, they also cause intense vasoconstriction and increase myocardial oxygen consumption, which might be detrimental.2015 Evidence SummaryThere are no pediatric studies that demonstrate the effectiveness of any vasopressors (epinephrine, or combination of vasopressors) in cardiac arrest. Two pediatric observational out-of-hospital studies58,59 had too many confounders to determine if vasopressors were beneficial. One adult OHCA randomized controlled trial60 showed epinephrine use was associated with increased ROSC and survival to hospital admission but no improvement in survival to hospital discharge.2015 Recommendation—NewIt is reasonable to administer epinephrine in pediatric cardiac arrest (Class IIa, LOE C-LD).Amiodarone and Lidocaine for Shock-Refractory VF and pVTPeds 825The 2005 and 2010 Guidelines recommended administering amiodarone in preference to lidocaine for the management of VF or pVT. This recommendation was based predominantly on pediatric case series or extrapolation from adult studies that used short-term outcomes.2015 Evidence SummaryNew pediatric observational data61 showed improved ROSC with the use of lidocaine as compared with amiodarone. Use of lidocaine compared with no lidocaine was significantly associated with an increased likelihood of ROSC. The same study did not show an association between lidocaine or amiodarone use and survival to hospital discharge.2015 Recommendation—NewFor shock-refractory VF or pVT, either amiodarone or lidocaine may be used (Class IIb, LOE C-LD).The Pediatric Cardiac Arrest Algorithm (Figure 3) reflects this change.Download figureDownload PowerPointFigure 3. Pediatric Cardiac Arrest Algorithm—2015 Update.Energy Doses for DefibrillationPeds 405The 2015 ILCOR systematic review addressed the dose of energy for pediatric manual defibrillation during cardiac arrest. Neither the energy dose specifically related to automated external defibrillators, nor the energy dose for cardioversion was evaluated in this evidence review.2015 Evidence SummaryTwo small case series demonstrated termination of VF/pVT with either 2 J/kg62 or 2 to 4 J/kg.63 In 1 observational study of IHCA,64 a higher initial energy dose of more than 3 to 5 J/kg was less effective than 1 to 3 J/kg in achieving ROSC. One small observational study of IHCA65 showed no benefit in achieving ROSC with a specific energy dose for initial defibrillation. Three small observational studies of IHCA and OHCA63,65,66 showed no survival to discharge advantage of any energy dose compared with 2 to 4 J/kg for initial defibrillation.2015 Recommendations—UpdatedIt is reasonable to use an initial dose of 2 to 4 J/kg of monophasic or biphasic energy for defibrillation (Class IIa, LOE C-LD), but for ease of teaching, an initial dose of 2 J/kg may be considered (Class IIb, LOE C-EO). For refractory VF, it is reasonable to increase the dose to 4 J/kg (Class IIa, LOE C-LD). For subsequent energy levels, a dose of 4 J/kg may be reasonable and higher energy levels may be considered, though not to exceed 10 J/kg or the adult maximum dose (Class IIb, LOE C-LD).Postarrest Care UpdatesPost–Cardiac Arrest Temperature ManagementPeds 387Data suggest that fever after pediatric cardiac arrest is common and is associated with poor outcomes.67 The 2010 AHA PALS Guidelines suggested a role for targeted temperature management after pediatric cardiac arrest (fever control for all patients, therapeutic hypothermia for some patients), but the recommendations were based predominantly on extrapolation from adult and asphyxiated newborn data.2015 Evidence SummaryA large multi-institutional, prospective, randomized study of pediatric patients (aged 2 days to 18 years) with OHCA found no difference in survival with good functional outcome at 1 year and no additional complications in comatose patients who were