Dallas 2015 TFQO: Vinay Nadkarni #375 EVREV 1: Vinay Nadkarni #375 EVREV 1: Dave Kloeck #126 Taskforce: Paeds Paed 424: Vasopressors in Paediatric cardiac arrest
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Dallas 2015
TFQO Vinay Nadkarni 375EVREV 1 Vinay Nadkarni 375EVREV 1 Dave Kloeck 126Taskforce Paeds
Paed 424 Vasopressors in Paediatric cardiac arrest
Dallas 2015COI Disclosure (specific to this systematic review)
Vinay Nadkarni COI375Commercialindustrybull Nil
Potential intellectual conflictsbull Nil
Dave Kloeck COI126Commercialindustrybull Nil
Potential intellectual conflictsbull Nil
Dallas 20152010 CoSTR
In1113088 adult and pediatric 1113088patients 1113088with1113088 cardiac 1113088arrest 1113088(pre1113088hospital 1113088[OHCA] 1113088or 1113088in1113088hospital 1113088[IHCA])1113088(P) 1113088does 1113088the 1113088use 1113088of1113088 vasopressin 1113088or 1113088vasopressin1113088+1113088epinephrine 1113088(I)1113088compared 1113088with1113088 standard 1113088treatment 1113088recommendations1113088(C) 1113088improve1113088 outcome 1113088(eg1113088ROSC 1113088survival 1113088to1113088 hospital 1113088discharge1113088or 1113088survival1113088 with 1113088favorable1113088 neurologic 1113088outcome) 1113088(O)
New question specific to Paeds ndash PICO edited to read - Infants and children in cardiac arrest (P) does use of NO vasopressor (epinephrine vasopressin combination of vasopressors) (I) compared with ANY use of vasopressors (C) change survival to 180 days with good neurological outcome survival to hospital discharge ROSC (O)
peter morley
Dallas 2015C2015 PICO
PopulationInfants and children in cardiac arrest
InterventionDoes the use of NO vasopressor (epinephrine vasopressin combination of vasopressors)
ComparisonCompared with ANY use of vasopressors
OutcomesSurvival to 180 days with good neurological outcome (9 ndash Critical)Survival to hospital discharge (6 ndash Important)ROSC (5 ndash Important)
Dallas 2015InclusionExclusionamp Articles Found
Inclusions (all studies)Infants and paediatricsAnimals ndash paediatric and infant
Number of articles initially identified = 1360 narrowed down to 10 articles
Number finally included in Evidence Profile tablesRCTs = 0non-RCTs = 2Excluded = 8
Later in review process ndash 1 adult RCT identified to answer the PICO question (ALS 788)ndash included into SoF but downgraded heavily for indirectness
Dallas 2015
ALS 788
Dallas 20152015 Proposed Treatment Recommendations
None
We suggest no change to current practise in using vasopressors for paediatric cardiac arrest
Strength of evidence is very low with very serious downgrades in quality assessment for inconsistency indirectness imprecision and risk of bias
Dallas 2015 Risk of Bias in studies
Dallas 2015
Evidence profile table
Dallas 2015
Evidence profile table
Dallas 2015Proposed Consensus on Science statements
For the critical outcome of ldquosurvival with good neurological outcomerdquo we have identified very low quality evidence (downgraded for indirectness imprecision inconsistency and high risk of bias) from two pediatric out of hospital case series observational studies including 74 patients suggesting uncertain benefit (Enright 2012 336 amp Diekmann 1995 901)(Pooled unadjusted OR 83 95 CI 149 ndash 4713)
For the important outcome of ldquosurvival to hospital dischargerdquo we have identified very low quality evidence (downgraded for indirectness imprecision inconsistency and high risk of bias) from two pediatric out of hospital case series observational studies including 74 patients suggesting uncertain benefit (Enright 2012 336 amp Diekmann 1995 901) (Pooled unadjusted OR 55 95 CI 12 ndash 258)
peter morley
We need to ensure that references are clear within SEERs ie First Author Year First page number format
peter morley
Some topics have very extensive CoS statements which would take many slides to cover or would need very small font
Dallas 2015
Proposed Consensus on Science statements
For the important outcome of ldquoROSCrdquo we have identified very low quality evidence (downgraded for indirectness imprecision inconsistency and high risk of bias) from two pediatric out of hospital case series observational studies including 74 patients suggesting uncertain benefit (Enright 2012 336 amp Diekmann 1995 901) (Pooled unadjusted OR 67 95 CI 15 to 297)
Note (See Adult PICO question 788)For all critical and important outcomes we reviewed and considered a single underpowered ADULT out-of-hospital cardiac arrest RCT that provided very low quality evidence (downgraded for extreme indirectness imprecision and risk of bias) comparing Standard Dose Epinephrine to placebo (Jacobs 2011 1138) For the critical outcome ldquogood neurological outcomerdquo and important outcome of ldquosurvival to dischargerdquo there was uncertain benefit or harm of standard dose epinephrine compared to placebo For the important outcomes of ldquoSurvival to Hospital Admissionrdquo and ldquoROSCrdquo there was possible benefit of standard dose epinephrine compared to placebo
Dallas 2015
Draft Treatment Recommendations
For paediatrics in cardiac arrest we suggest no change in the current approach
Therefore no change in the current practice of using vasopressors for paediatric cardiac arrest
Strength of evidence is very low with very serious downgrades in quality assessment for inconsistency indirectness imprecision and risk of bias
Dallas 2015Knowledge Gaps
If adult studies suggest that vasopressor administration is associated with improved ROSC but worse survival to hospital discharge and neurological outcome then prospective studies of placebo vs epinephrinevasopressors for paediatric cardiac arrest would be indicated
Are there selected resuscitation circumstances (eg pulmonary hypertension myocarditis imminent ECPR rescue) where the administration of vasopressors is not indicated
Dallas 2015Next Steps
Task force discussion ndash TR not appropriate and needs better wordsmithing proposal below
There is insufficient evidence of benefit or harm from using no vasopressors compared to any vasopressors to treat infants and children in cardiac arrest
Until specific studies of this question We suggest providers continue to use epinephrine for pediatric cardiac arrest as per their current council-specific practice
Dallas 2015COI Disclosure (specific to this systematic review)
Vinay Nadkarni COI375Commercialindustrybull Nil
Potential intellectual conflictsbull Nil
Dave Kloeck COI126Commercialindustrybull Nil
Potential intellectual conflictsbull Nil
Dallas 20152010 CoSTR
In1113088 adult and pediatric 1113088patients 1113088with1113088 cardiac 1113088arrest 1113088(pre1113088hospital 1113088[OHCA] 1113088or 1113088in1113088hospital 1113088[IHCA])1113088(P) 1113088does 1113088the 1113088use 1113088of1113088 vasopressin 1113088or 1113088vasopressin1113088+1113088epinephrine 1113088(I)1113088compared 1113088with1113088 standard 1113088treatment 1113088recommendations1113088(C) 1113088improve1113088 outcome 1113088(eg1113088ROSC 1113088survival 1113088to1113088 hospital 1113088discharge1113088or 1113088survival1113088 with 1113088favorable1113088 neurologic 1113088outcome) 1113088(O)
New question specific to Paeds ndash PICO edited to read - Infants and children in cardiac arrest (P) does use of NO vasopressor (epinephrine vasopressin combination of vasopressors) (I) compared with ANY use of vasopressors (C) change survival to 180 days with good neurological outcome survival to hospital discharge ROSC (O)
peter morley
Dallas 2015C2015 PICO
PopulationInfants and children in cardiac arrest
InterventionDoes the use of NO vasopressor (epinephrine vasopressin combination of vasopressors)
ComparisonCompared with ANY use of vasopressors
OutcomesSurvival to 180 days with good neurological outcome (9 ndash Critical)Survival to hospital discharge (6 ndash Important)ROSC (5 ndash Important)
Dallas 2015InclusionExclusionamp Articles Found
Inclusions (all studies)Infants and paediatricsAnimals ndash paediatric and infant
Number of articles initially identified = 1360 narrowed down to 10 articles
Number finally included in Evidence Profile tablesRCTs = 0non-RCTs = 2Excluded = 8
Later in review process ndash 1 adult RCT identified to answer the PICO question (ALS 788)ndash included into SoF but downgraded heavily for indirectness
Dallas 2015
ALS 788
Dallas 20152015 Proposed Treatment Recommendations
None
We suggest no change to current practise in using vasopressors for paediatric cardiac arrest
Strength of evidence is very low with very serious downgrades in quality assessment for inconsistency indirectness imprecision and risk of bias
Dallas 2015 Risk of Bias in studies
Dallas 2015
Evidence profile table
Dallas 2015
Evidence profile table
Dallas 2015Proposed Consensus on Science statements
For the critical outcome of ldquosurvival with good neurological outcomerdquo we have identified very low quality evidence (downgraded for indirectness imprecision inconsistency and high risk of bias) from two pediatric out of hospital case series observational studies including 74 patients suggesting uncertain benefit (Enright 2012 336 amp Diekmann 1995 901)(Pooled unadjusted OR 83 95 CI 149 ndash 4713)
For the important outcome of ldquosurvival to hospital dischargerdquo we have identified very low quality evidence (downgraded for indirectness imprecision inconsistency and high risk of bias) from two pediatric out of hospital case series observational studies including 74 patients suggesting uncertain benefit (Enright 2012 336 amp Diekmann 1995 901) (Pooled unadjusted OR 55 95 CI 12 ndash 258)
peter morley
We need to ensure that references are clear within SEERs ie First Author Year First page number format
peter morley
Some topics have very extensive CoS statements which would take many slides to cover or would need very small font
Dallas 2015
Proposed Consensus on Science statements
For the important outcome of ldquoROSCrdquo we have identified very low quality evidence (downgraded for indirectness imprecision inconsistency and high risk of bias) from two pediatric out of hospital case series observational studies including 74 patients suggesting uncertain benefit (Enright 2012 336 amp Diekmann 1995 901) (Pooled unadjusted OR 67 95 CI 15 to 297)
Note (See Adult PICO question 788)For all critical and important outcomes we reviewed and considered a single underpowered ADULT out-of-hospital cardiac arrest RCT that provided very low quality evidence (downgraded for extreme indirectness imprecision and risk of bias) comparing Standard Dose Epinephrine to placebo (Jacobs 2011 1138) For the critical outcome ldquogood neurological outcomerdquo and important outcome of ldquosurvival to dischargerdquo there was uncertain benefit or harm of standard dose epinephrine compared to placebo For the important outcomes of ldquoSurvival to Hospital Admissionrdquo and ldquoROSCrdquo there was possible benefit of standard dose epinephrine compared to placebo
Dallas 2015
Draft Treatment Recommendations
For paediatrics in cardiac arrest we suggest no change in the current approach
Therefore no change in the current practice of using vasopressors for paediatric cardiac arrest
Strength of evidence is very low with very serious downgrades in quality assessment for inconsistency indirectness imprecision and risk of bias
Dallas 2015Knowledge Gaps
If adult studies suggest that vasopressor administration is associated with improved ROSC but worse survival to hospital discharge and neurological outcome then prospective studies of placebo vs epinephrinevasopressors for paediatric cardiac arrest would be indicated
Are there selected resuscitation circumstances (eg pulmonary hypertension myocarditis imminent ECPR rescue) where the administration of vasopressors is not indicated
Dallas 2015Next Steps
Task force discussion ndash TR not appropriate and needs better wordsmithing proposal below
There is insufficient evidence of benefit or harm from using no vasopressors compared to any vasopressors to treat infants and children in cardiac arrest
Until specific studies of this question We suggest providers continue to use epinephrine for pediatric cardiac arrest as per their current council-specific practice
Dallas 20152010 CoSTR
In1113088 adult and pediatric 1113088patients 1113088with1113088 cardiac 1113088arrest 1113088(pre1113088hospital 1113088[OHCA] 1113088or 1113088in1113088hospital 1113088[IHCA])1113088(P) 1113088does 1113088the 1113088use 1113088of1113088 vasopressin 1113088or 1113088vasopressin1113088+1113088epinephrine 1113088(I)1113088compared 1113088with1113088 standard 1113088treatment 1113088recommendations1113088(C) 1113088improve1113088 outcome 1113088(eg1113088ROSC 1113088survival 1113088to1113088 hospital 1113088discharge1113088or 1113088survival1113088 with 1113088favorable1113088 neurologic 1113088outcome) 1113088(O)
New question specific to Paeds ndash PICO edited to read - Infants and children in cardiac arrest (P) does use of NO vasopressor (epinephrine vasopressin combination of vasopressors) (I) compared with ANY use of vasopressors (C) change survival to 180 days with good neurological outcome survival to hospital discharge ROSC (O)
peter morley
Dallas 2015C2015 PICO
PopulationInfants and children in cardiac arrest
InterventionDoes the use of NO vasopressor (epinephrine vasopressin combination of vasopressors)
ComparisonCompared with ANY use of vasopressors
OutcomesSurvival to 180 days with good neurological outcome (9 ndash Critical)Survival to hospital discharge (6 ndash Important)ROSC (5 ndash Important)
Dallas 2015InclusionExclusionamp Articles Found
Inclusions (all studies)Infants and paediatricsAnimals ndash paediatric and infant
Number of articles initially identified = 1360 narrowed down to 10 articles
Number finally included in Evidence Profile tablesRCTs = 0non-RCTs = 2Excluded = 8
Later in review process ndash 1 adult RCT identified to answer the PICO question (ALS 788)ndash included into SoF but downgraded heavily for indirectness
Dallas 2015
ALS 788
Dallas 20152015 Proposed Treatment Recommendations
None
We suggest no change to current practise in using vasopressors for paediatric cardiac arrest
Strength of evidence is very low with very serious downgrades in quality assessment for inconsistency indirectness imprecision and risk of bias
Dallas 2015 Risk of Bias in studies
Dallas 2015
Evidence profile table
Dallas 2015
Evidence profile table
Dallas 2015Proposed Consensus on Science statements
For the critical outcome of ldquosurvival with good neurological outcomerdquo we have identified very low quality evidence (downgraded for indirectness imprecision inconsistency and high risk of bias) from two pediatric out of hospital case series observational studies including 74 patients suggesting uncertain benefit (Enright 2012 336 amp Diekmann 1995 901)(Pooled unadjusted OR 83 95 CI 149 ndash 4713)
For the important outcome of ldquosurvival to hospital dischargerdquo we have identified very low quality evidence (downgraded for indirectness imprecision inconsistency and high risk of bias) from two pediatric out of hospital case series observational studies including 74 patients suggesting uncertain benefit (Enright 2012 336 amp Diekmann 1995 901) (Pooled unadjusted OR 55 95 CI 12 ndash 258)
peter morley
We need to ensure that references are clear within SEERs ie First Author Year First page number format
peter morley
Some topics have very extensive CoS statements which would take many slides to cover or would need very small font
Dallas 2015
Proposed Consensus on Science statements
For the important outcome of ldquoROSCrdquo we have identified very low quality evidence (downgraded for indirectness imprecision inconsistency and high risk of bias) from two pediatric out of hospital case series observational studies including 74 patients suggesting uncertain benefit (Enright 2012 336 amp Diekmann 1995 901) (Pooled unadjusted OR 67 95 CI 15 to 297)
Note (See Adult PICO question 788)For all critical and important outcomes we reviewed and considered a single underpowered ADULT out-of-hospital cardiac arrest RCT that provided very low quality evidence (downgraded for extreme indirectness imprecision and risk of bias) comparing Standard Dose Epinephrine to placebo (Jacobs 2011 1138) For the critical outcome ldquogood neurological outcomerdquo and important outcome of ldquosurvival to dischargerdquo there was uncertain benefit or harm of standard dose epinephrine compared to placebo For the important outcomes of ldquoSurvival to Hospital Admissionrdquo and ldquoROSCrdquo there was possible benefit of standard dose epinephrine compared to placebo
Dallas 2015
Draft Treatment Recommendations
For paediatrics in cardiac arrest we suggest no change in the current approach
Therefore no change in the current practice of using vasopressors for paediatric cardiac arrest
Strength of evidence is very low with very serious downgrades in quality assessment for inconsistency indirectness imprecision and risk of bias
Dallas 2015Knowledge Gaps
If adult studies suggest that vasopressor administration is associated with improved ROSC but worse survival to hospital discharge and neurological outcome then prospective studies of placebo vs epinephrinevasopressors for paediatric cardiac arrest would be indicated
Are there selected resuscitation circumstances (eg pulmonary hypertension myocarditis imminent ECPR rescue) where the administration of vasopressors is not indicated
Dallas 2015Next Steps
Task force discussion ndash TR not appropriate and needs better wordsmithing proposal below
There is insufficient evidence of benefit or harm from using no vasopressors compared to any vasopressors to treat infants and children in cardiac arrest
Until specific studies of this question We suggest providers continue to use epinephrine for pediatric cardiac arrest as per their current council-specific practice
Dallas 2015C2015 PICO
PopulationInfants and children in cardiac arrest
InterventionDoes the use of NO vasopressor (epinephrine vasopressin combination of vasopressors)
ComparisonCompared with ANY use of vasopressors
OutcomesSurvival to 180 days with good neurological outcome (9 ndash Critical)Survival to hospital discharge (6 ndash Important)ROSC (5 ndash Important)
Dallas 2015InclusionExclusionamp Articles Found
Inclusions (all studies)Infants and paediatricsAnimals ndash paediatric and infant
Number of articles initially identified = 1360 narrowed down to 10 articles
Number finally included in Evidence Profile tablesRCTs = 0non-RCTs = 2Excluded = 8
Later in review process ndash 1 adult RCT identified to answer the PICO question (ALS 788)ndash included into SoF but downgraded heavily for indirectness
Dallas 2015
ALS 788
Dallas 20152015 Proposed Treatment Recommendations
None
We suggest no change to current practise in using vasopressors for paediatric cardiac arrest
Strength of evidence is very low with very serious downgrades in quality assessment for inconsistency indirectness imprecision and risk of bias
Dallas 2015 Risk of Bias in studies
Dallas 2015
Evidence profile table
Dallas 2015
Evidence profile table
Dallas 2015Proposed Consensus on Science statements
For the critical outcome of ldquosurvival with good neurological outcomerdquo we have identified very low quality evidence (downgraded for indirectness imprecision inconsistency and high risk of bias) from two pediatric out of hospital case series observational studies including 74 patients suggesting uncertain benefit (Enright 2012 336 amp Diekmann 1995 901)(Pooled unadjusted OR 83 95 CI 149 ndash 4713)
For the important outcome of ldquosurvival to hospital dischargerdquo we have identified very low quality evidence (downgraded for indirectness imprecision inconsistency and high risk of bias) from two pediatric out of hospital case series observational studies including 74 patients suggesting uncertain benefit (Enright 2012 336 amp Diekmann 1995 901) (Pooled unadjusted OR 55 95 CI 12 ndash 258)
peter morley
We need to ensure that references are clear within SEERs ie First Author Year First page number format
peter morley
Some topics have very extensive CoS statements which would take many slides to cover or would need very small font
Dallas 2015
Proposed Consensus on Science statements
For the important outcome of ldquoROSCrdquo we have identified very low quality evidence (downgraded for indirectness imprecision inconsistency and high risk of bias) from two pediatric out of hospital case series observational studies including 74 patients suggesting uncertain benefit (Enright 2012 336 amp Diekmann 1995 901) (Pooled unadjusted OR 67 95 CI 15 to 297)
Note (See Adult PICO question 788)For all critical and important outcomes we reviewed and considered a single underpowered ADULT out-of-hospital cardiac arrest RCT that provided very low quality evidence (downgraded for extreme indirectness imprecision and risk of bias) comparing Standard Dose Epinephrine to placebo (Jacobs 2011 1138) For the critical outcome ldquogood neurological outcomerdquo and important outcome of ldquosurvival to dischargerdquo there was uncertain benefit or harm of standard dose epinephrine compared to placebo For the important outcomes of ldquoSurvival to Hospital Admissionrdquo and ldquoROSCrdquo there was possible benefit of standard dose epinephrine compared to placebo
Dallas 2015
Draft Treatment Recommendations
For paediatrics in cardiac arrest we suggest no change in the current approach
Therefore no change in the current practice of using vasopressors for paediatric cardiac arrest
Strength of evidence is very low with very serious downgrades in quality assessment for inconsistency indirectness imprecision and risk of bias
Dallas 2015Knowledge Gaps
If adult studies suggest that vasopressor administration is associated with improved ROSC but worse survival to hospital discharge and neurological outcome then prospective studies of placebo vs epinephrinevasopressors for paediatric cardiac arrest would be indicated
Are there selected resuscitation circumstances (eg pulmonary hypertension myocarditis imminent ECPR rescue) where the administration of vasopressors is not indicated
Dallas 2015Next Steps
Task force discussion ndash TR not appropriate and needs better wordsmithing proposal below
There is insufficient evidence of benefit or harm from using no vasopressors compared to any vasopressors to treat infants and children in cardiac arrest
Until specific studies of this question We suggest providers continue to use epinephrine for pediatric cardiac arrest as per their current council-specific practice
Dallas 2015InclusionExclusionamp Articles Found
Inclusions (all studies)Infants and paediatricsAnimals ndash paediatric and infant
Number of articles initially identified = 1360 narrowed down to 10 articles
Number finally included in Evidence Profile tablesRCTs = 0non-RCTs = 2Excluded = 8
Later in review process ndash 1 adult RCT identified to answer the PICO question (ALS 788)ndash included into SoF but downgraded heavily for indirectness
Dallas 2015
ALS 788
Dallas 20152015 Proposed Treatment Recommendations
None
We suggest no change to current practise in using vasopressors for paediatric cardiac arrest
Strength of evidence is very low with very serious downgrades in quality assessment for inconsistency indirectness imprecision and risk of bias
Dallas 2015 Risk of Bias in studies
Dallas 2015
Evidence profile table
Dallas 2015
Evidence profile table
Dallas 2015Proposed Consensus on Science statements
For the critical outcome of ldquosurvival with good neurological outcomerdquo we have identified very low quality evidence (downgraded for indirectness imprecision inconsistency and high risk of bias) from two pediatric out of hospital case series observational studies including 74 patients suggesting uncertain benefit (Enright 2012 336 amp Diekmann 1995 901)(Pooled unadjusted OR 83 95 CI 149 ndash 4713)
For the important outcome of ldquosurvival to hospital dischargerdquo we have identified very low quality evidence (downgraded for indirectness imprecision inconsistency and high risk of bias) from two pediatric out of hospital case series observational studies including 74 patients suggesting uncertain benefit (Enright 2012 336 amp Diekmann 1995 901) (Pooled unadjusted OR 55 95 CI 12 ndash 258)
peter morley
We need to ensure that references are clear within SEERs ie First Author Year First page number format
peter morley
Some topics have very extensive CoS statements which would take many slides to cover or would need very small font
Dallas 2015
Proposed Consensus on Science statements
For the important outcome of ldquoROSCrdquo we have identified very low quality evidence (downgraded for indirectness imprecision inconsistency and high risk of bias) from two pediatric out of hospital case series observational studies including 74 patients suggesting uncertain benefit (Enright 2012 336 amp Diekmann 1995 901) (Pooled unadjusted OR 67 95 CI 15 to 297)
Note (See Adult PICO question 788)For all critical and important outcomes we reviewed and considered a single underpowered ADULT out-of-hospital cardiac arrest RCT that provided very low quality evidence (downgraded for extreme indirectness imprecision and risk of bias) comparing Standard Dose Epinephrine to placebo (Jacobs 2011 1138) For the critical outcome ldquogood neurological outcomerdquo and important outcome of ldquosurvival to dischargerdquo there was uncertain benefit or harm of standard dose epinephrine compared to placebo For the important outcomes of ldquoSurvival to Hospital Admissionrdquo and ldquoROSCrdquo there was possible benefit of standard dose epinephrine compared to placebo
Dallas 2015
Draft Treatment Recommendations
For paediatrics in cardiac arrest we suggest no change in the current approach
Therefore no change in the current practice of using vasopressors for paediatric cardiac arrest
Strength of evidence is very low with very serious downgrades in quality assessment for inconsistency indirectness imprecision and risk of bias
Dallas 2015Knowledge Gaps
If adult studies suggest that vasopressor administration is associated with improved ROSC but worse survival to hospital discharge and neurological outcome then prospective studies of placebo vs epinephrinevasopressors for paediatric cardiac arrest would be indicated
Are there selected resuscitation circumstances (eg pulmonary hypertension myocarditis imminent ECPR rescue) where the administration of vasopressors is not indicated
Dallas 2015Next Steps
Task force discussion ndash TR not appropriate and needs better wordsmithing proposal below
There is insufficient evidence of benefit or harm from using no vasopressors compared to any vasopressors to treat infants and children in cardiac arrest
Until specific studies of this question We suggest providers continue to use epinephrine for pediatric cardiac arrest as per their current council-specific practice
Dallas 2015
ALS 788
Dallas 20152015 Proposed Treatment Recommendations
None
We suggest no change to current practise in using vasopressors for paediatric cardiac arrest
Strength of evidence is very low with very serious downgrades in quality assessment for inconsistency indirectness imprecision and risk of bias
Dallas 2015 Risk of Bias in studies
Dallas 2015
Evidence profile table
Dallas 2015
Evidence profile table
Dallas 2015Proposed Consensus on Science statements
For the critical outcome of ldquosurvival with good neurological outcomerdquo we have identified very low quality evidence (downgraded for indirectness imprecision inconsistency and high risk of bias) from two pediatric out of hospital case series observational studies including 74 patients suggesting uncertain benefit (Enright 2012 336 amp Diekmann 1995 901)(Pooled unadjusted OR 83 95 CI 149 ndash 4713)
For the important outcome of ldquosurvival to hospital dischargerdquo we have identified very low quality evidence (downgraded for indirectness imprecision inconsistency and high risk of bias) from two pediatric out of hospital case series observational studies including 74 patients suggesting uncertain benefit (Enright 2012 336 amp Diekmann 1995 901) (Pooled unadjusted OR 55 95 CI 12 ndash 258)
peter morley
We need to ensure that references are clear within SEERs ie First Author Year First page number format
peter morley
Some topics have very extensive CoS statements which would take many slides to cover or would need very small font
Dallas 2015
Proposed Consensus on Science statements
For the important outcome of ldquoROSCrdquo we have identified very low quality evidence (downgraded for indirectness imprecision inconsistency and high risk of bias) from two pediatric out of hospital case series observational studies including 74 patients suggesting uncertain benefit (Enright 2012 336 amp Diekmann 1995 901) (Pooled unadjusted OR 67 95 CI 15 to 297)
Note (See Adult PICO question 788)For all critical and important outcomes we reviewed and considered a single underpowered ADULT out-of-hospital cardiac arrest RCT that provided very low quality evidence (downgraded for extreme indirectness imprecision and risk of bias) comparing Standard Dose Epinephrine to placebo (Jacobs 2011 1138) For the critical outcome ldquogood neurological outcomerdquo and important outcome of ldquosurvival to dischargerdquo there was uncertain benefit or harm of standard dose epinephrine compared to placebo For the important outcomes of ldquoSurvival to Hospital Admissionrdquo and ldquoROSCrdquo there was possible benefit of standard dose epinephrine compared to placebo
Dallas 2015
Draft Treatment Recommendations
For paediatrics in cardiac arrest we suggest no change in the current approach
Therefore no change in the current practice of using vasopressors for paediatric cardiac arrest
Strength of evidence is very low with very serious downgrades in quality assessment for inconsistency indirectness imprecision and risk of bias
Dallas 2015Knowledge Gaps
If adult studies suggest that vasopressor administration is associated with improved ROSC but worse survival to hospital discharge and neurological outcome then prospective studies of placebo vs epinephrinevasopressors for paediatric cardiac arrest would be indicated
Are there selected resuscitation circumstances (eg pulmonary hypertension myocarditis imminent ECPR rescue) where the administration of vasopressors is not indicated
Dallas 2015Next Steps
Task force discussion ndash TR not appropriate and needs better wordsmithing proposal below
There is insufficient evidence of benefit or harm from using no vasopressors compared to any vasopressors to treat infants and children in cardiac arrest
Until specific studies of this question We suggest providers continue to use epinephrine for pediatric cardiac arrest as per their current council-specific practice
Dallas 20152015 Proposed Treatment Recommendations
None
We suggest no change to current practise in using vasopressors for paediatric cardiac arrest
Strength of evidence is very low with very serious downgrades in quality assessment for inconsistency indirectness imprecision and risk of bias
Dallas 2015 Risk of Bias in studies
Dallas 2015
Evidence profile table
Dallas 2015
Evidence profile table
Dallas 2015Proposed Consensus on Science statements
For the critical outcome of ldquosurvival with good neurological outcomerdquo we have identified very low quality evidence (downgraded for indirectness imprecision inconsistency and high risk of bias) from two pediatric out of hospital case series observational studies including 74 patients suggesting uncertain benefit (Enright 2012 336 amp Diekmann 1995 901)(Pooled unadjusted OR 83 95 CI 149 ndash 4713)
For the important outcome of ldquosurvival to hospital dischargerdquo we have identified very low quality evidence (downgraded for indirectness imprecision inconsistency and high risk of bias) from two pediatric out of hospital case series observational studies including 74 patients suggesting uncertain benefit (Enright 2012 336 amp Diekmann 1995 901) (Pooled unadjusted OR 55 95 CI 12 ndash 258)
peter morley
We need to ensure that references are clear within SEERs ie First Author Year First page number format
peter morley
Some topics have very extensive CoS statements which would take many slides to cover or would need very small font
Dallas 2015
Proposed Consensus on Science statements
For the important outcome of ldquoROSCrdquo we have identified very low quality evidence (downgraded for indirectness imprecision inconsistency and high risk of bias) from two pediatric out of hospital case series observational studies including 74 patients suggesting uncertain benefit (Enright 2012 336 amp Diekmann 1995 901) (Pooled unadjusted OR 67 95 CI 15 to 297)
Note (See Adult PICO question 788)For all critical and important outcomes we reviewed and considered a single underpowered ADULT out-of-hospital cardiac arrest RCT that provided very low quality evidence (downgraded for extreme indirectness imprecision and risk of bias) comparing Standard Dose Epinephrine to placebo (Jacobs 2011 1138) For the critical outcome ldquogood neurological outcomerdquo and important outcome of ldquosurvival to dischargerdquo there was uncertain benefit or harm of standard dose epinephrine compared to placebo For the important outcomes of ldquoSurvival to Hospital Admissionrdquo and ldquoROSCrdquo there was possible benefit of standard dose epinephrine compared to placebo
Dallas 2015
Draft Treatment Recommendations
For paediatrics in cardiac arrest we suggest no change in the current approach
Therefore no change in the current practice of using vasopressors for paediatric cardiac arrest
Strength of evidence is very low with very serious downgrades in quality assessment for inconsistency indirectness imprecision and risk of bias
Dallas 2015Knowledge Gaps
If adult studies suggest that vasopressor administration is associated with improved ROSC but worse survival to hospital discharge and neurological outcome then prospective studies of placebo vs epinephrinevasopressors for paediatric cardiac arrest would be indicated
Are there selected resuscitation circumstances (eg pulmonary hypertension myocarditis imminent ECPR rescue) where the administration of vasopressors is not indicated
Dallas 2015Next Steps
Task force discussion ndash TR not appropriate and needs better wordsmithing proposal below
There is insufficient evidence of benefit or harm from using no vasopressors compared to any vasopressors to treat infants and children in cardiac arrest
Until specific studies of this question We suggest providers continue to use epinephrine for pediatric cardiac arrest as per their current council-specific practice
Dallas 2015 Risk of Bias in studies
Dallas 2015
Evidence profile table
Dallas 2015
Evidence profile table
Dallas 2015Proposed Consensus on Science statements
For the critical outcome of ldquosurvival with good neurological outcomerdquo we have identified very low quality evidence (downgraded for indirectness imprecision inconsistency and high risk of bias) from two pediatric out of hospital case series observational studies including 74 patients suggesting uncertain benefit (Enright 2012 336 amp Diekmann 1995 901)(Pooled unadjusted OR 83 95 CI 149 ndash 4713)
For the important outcome of ldquosurvival to hospital dischargerdquo we have identified very low quality evidence (downgraded for indirectness imprecision inconsistency and high risk of bias) from two pediatric out of hospital case series observational studies including 74 patients suggesting uncertain benefit (Enright 2012 336 amp Diekmann 1995 901) (Pooled unadjusted OR 55 95 CI 12 ndash 258)
peter morley
We need to ensure that references are clear within SEERs ie First Author Year First page number format
peter morley
Some topics have very extensive CoS statements which would take many slides to cover or would need very small font
Dallas 2015
Proposed Consensus on Science statements
For the important outcome of ldquoROSCrdquo we have identified very low quality evidence (downgraded for indirectness imprecision inconsistency and high risk of bias) from two pediatric out of hospital case series observational studies including 74 patients suggesting uncertain benefit (Enright 2012 336 amp Diekmann 1995 901) (Pooled unadjusted OR 67 95 CI 15 to 297)
Note (See Adult PICO question 788)For all critical and important outcomes we reviewed and considered a single underpowered ADULT out-of-hospital cardiac arrest RCT that provided very low quality evidence (downgraded for extreme indirectness imprecision and risk of bias) comparing Standard Dose Epinephrine to placebo (Jacobs 2011 1138) For the critical outcome ldquogood neurological outcomerdquo and important outcome of ldquosurvival to dischargerdquo there was uncertain benefit or harm of standard dose epinephrine compared to placebo For the important outcomes of ldquoSurvival to Hospital Admissionrdquo and ldquoROSCrdquo there was possible benefit of standard dose epinephrine compared to placebo
Dallas 2015
Draft Treatment Recommendations
For paediatrics in cardiac arrest we suggest no change in the current approach
Therefore no change in the current practice of using vasopressors for paediatric cardiac arrest
Strength of evidence is very low with very serious downgrades in quality assessment for inconsistency indirectness imprecision and risk of bias
Dallas 2015Knowledge Gaps
If adult studies suggest that vasopressor administration is associated with improved ROSC but worse survival to hospital discharge and neurological outcome then prospective studies of placebo vs epinephrinevasopressors for paediatric cardiac arrest would be indicated
Are there selected resuscitation circumstances (eg pulmonary hypertension myocarditis imminent ECPR rescue) where the administration of vasopressors is not indicated
Dallas 2015Next Steps
Task force discussion ndash TR not appropriate and needs better wordsmithing proposal below
There is insufficient evidence of benefit or harm from using no vasopressors compared to any vasopressors to treat infants and children in cardiac arrest
Until specific studies of this question We suggest providers continue to use epinephrine for pediatric cardiac arrest as per their current council-specific practice
Dallas 2015
Evidence profile table
Dallas 2015
Evidence profile table
Dallas 2015Proposed Consensus on Science statements
For the critical outcome of ldquosurvival with good neurological outcomerdquo we have identified very low quality evidence (downgraded for indirectness imprecision inconsistency and high risk of bias) from two pediatric out of hospital case series observational studies including 74 patients suggesting uncertain benefit (Enright 2012 336 amp Diekmann 1995 901)(Pooled unadjusted OR 83 95 CI 149 ndash 4713)
For the important outcome of ldquosurvival to hospital dischargerdquo we have identified very low quality evidence (downgraded for indirectness imprecision inconsistency and high risk of bias) from two pediatric out of hospital case series observational studies including 74 patients suggesting uncertain benefit (Enright 2012 336 amp Diekmann 1995 901) (Pooled unadjusted OR 55 95 CI 12 ndash 258)
peter morley
We need to ensure that references are clear within SEERs ie First Author Year First page number format
peter morley
Some topics have very extensive CoS statements which would take many slides to cover or would need very small font
Dallas 2015
Proposed Consensus on Science statements
For the important outcome of ldquoROSCrdquo we have identified very low quality evidence (downgraded for indirectness imprecision inconsistency and high risk of bias) from two pediatric out of hospital case series observational studies including 74 patients suggesting uncertain benefit (Enright 2012 336 amp Diekmann 1995 901) (Pooled unadjusted OR 67 95 CI 15 to 297)
Note (See Adult PICO question 788)For all critical and important outcomes we reviewed and considered a single underpowered ADULT out-of-hospital cardiac arrest RCT that provided very low quality evidence (downgraded for extreme indirectness imprecision and risk of bias) comparing Standard Dose Epinephrine to placebo (Jacobs 2011 1138) For the critical outcome ldquogood neurological outcomerdquo and important outcome of ldquosurvival to dischargerdquo there was uncertain benefit or harm of standard dose epinephrine compared to placebo For the important outcomes of ldquoSurvival to Hospital Admissionrdquo and ldquoROSCrdquo there was possible benefit of standard dose epinephrine compared to placebo
Dallas 2015
Draft Treatment Recommendations
For paediatrics in cardiac arrest we suggest no change in the current approach
Therefore no change in the current practice of using vasopressors for paediatric cardiac arrest
Strength of evidence is very low with very serious downgrades in quality assessment for inconsistency indirectness imprecision and risk of bias
Dallas 2015Knowledge Gaps
If adult studies suggest that vasopressor administration is associated with improved ROSC but worse survival to hospital discharge and neurological outcome then prospective studies of placebo vs epinephrinevasopressors for paediatric cardiac arrest would be indicated
Are there selected resuscitation circumstances (eg pulmonary hypertension myocarditis imminent ECPR rescue) where the administration of vasopressors is not indicated
Dallas 2015Next Steps
Task force discussion ndash TR not appropriate and needs better wordsmithing proposal below
There is insufficient evidence of benefit or harm from using no vasopressors compared to any vasopressors to treat infants and children in cardiac arrest
Until specific studies of this question We suggest providers continue to use epinephrine for pediatric cardiac arrest as per their current council-specific practice
Dallas 2015
Evidence profile table
Dallas 2015Proposed Consensus on Science statements
For the critical outcome of ldquosurvival with good neurological outcomerdquo we have identified very low quality evidence (downgraded for indirectness imprecision inconsistency and high risk of bias) from two pediatric out of hospital case series observational studies including 74 patients suggesting uncertain benefit (Enright 2012 336 amp Diekmann 1995 901)(Pooled unadjusted OR 83 95 CI 149 ndash 4713)
For the important outcome of ldquosurvival to hospital dischargerdquo we have identified very low quality evidence (downgraded for indirectness imprecision inconsistency and high risk of bias) from two pediatric out of hospital case series observational studies including 74 patients suggesting uncertain benefit (Enright 2012 336 amp Diekmann 1995 901) (Pooled unadjusted OR 55 95 CI 12 ndash 258)
peter morley
We need to ensure that references are clear within SEERs ie First Author Year First page number format
peter morley
Some topics have very extensive CoS statements which would take many slides to cover or would need very small font
Dallas 2015
Proposed Consensus on Science statements
For the important outcome of ldquoROSCrdquo we have identified very low quality evidence (downgraded for indirectness imprecision inconsistency and high risk of bias) from two pediatric out of hospital case series observational studies including 74 patients suggesting uncertain benefit (Enright 2012 336 amp Diekmann 1995 901) (Pooled unadjusted OR 67 95 CI 15 to 297)
Note (See Adult PICO question 788)For all critical and important outcomes we reviewed and considered a single underpowered ADULT out-of-hospital cardiac arrest RCT that provided very low quality evidence (downgraded for extreme indirectness imprecision and risk of bias) comparing Standard Dose Epinephrine to placebo (Jacobs 2011 1138) For the critical outcome ldquogood neurological outcomerdquo and important outcome of ldquosurvival to dischargerdquo there was uncertain benefit or harm of standard dose epinephrine compared to placebo For the important outcomes of ldquoSurvival to Hospital Admissionrdquo and ldquoROSCrdquo there was possible benefit of standard dose epinephrine compared to placebo
Dallas 2015
Draft Treatment Recommendations
For paediatrics in cardiac arrest we suggest no change in the current approach
Therefore no change in the current practice of using vasopressors for paediatric cardiac arrest
Strength of evidence is very low with very serious downgrades in quality assessment for inconsistency indirectness imprecision and risk of bias
Dallas 2015Knowledge Gaps
If adult studies suggest that vasopressor administration is associated with improved ROSC but worse survival to hospital discharge and neurological outcome then prospective studies of placebo vs epinephrinevasopressors for paediatric cardiac arrest would be indicated
Are there selected resuscitation circumstances (eg pulmonary hypertension myocarditis imminent ECPR rescue) where the administration of vasopressors is not indicated
Dallas 2015Next Steps
Task force discussion ndash TR not appropriate and needs better wordsmithing proposal below
There is insufficient evidence of benefit or harm from using no vasopressors compared to any vasopressors to treat infants and children in cardiac arrest
Until specific studies of this question We suggest providers continue to use epinephrine for pediatric cardiac arrest as per their current council-specific practice
Dallas 2015Proposed Consensus on Science statements
For the critical outcome of ldquosurvival with good neurological outcomerdquo we have identified very low quality evidence (downgraded for indirectness imprecision inconsistency and high risk of bias) from two pediatric out of hospital case series observational studies including 74 patients suggesting uncertain benefit (Enright 2012 336 amp Diekmann 1995 901)(Pooled unadjusted OR 83 95 CI 149 ndash 4713)
For the important outcome of ldquosurvival to hospital dischargerdquo we have identified very low quality evidence (downgraded for indirectness imprecision inconsistency and high risk of bias) from two pediatric out of hospital case series observational studies including 74 patients suggesting uncertain benefit (Enright 2012 336 amp Diekmann 1995 901) (Pooled unadjusted OR 55 95 CI 12 ndash 258)
peter morley
We need to ensure that references are clear within SEERs ie First Author Year First page number format
peter morley
Some topics have very extensive CoS statements which would take many slides to cover or would need very small font
Dallas 2015
Proposed Consensus on Science statements
For the important outcome of ldquoROSCrdquo we have identified very low quality evidence (downgraded for indirectness imprecision inconsistency and high risk of bias) from two pediatric out of hospital case series observational studies including 74 patients suggesting uncertain benefit (Enright 2012 336 amp Diekmann 1995 901) (Pooled unadjusted OR 67 95 CI 15 to 297)
Note (See Adult PICO question 788)For all critical and important outcomes we reviewed and considered a single underpowered ADULT out-of-hospital cardiac arrest RCT that provided very low quality evidence (downgraded for extreme indirectness imprecision and risk of bias) comparing Standard Dose Epinephrine to placebo (Jacobs 2011 1138) For the critical outcome ldquogood neurological outcomerdquo and important outcome of ldquosurvival to dischargerdquo there was uncertain benefit or harm of standard dose epinephrine compared to placebo For the important outcomes of ldquoSurvival to Hospital Admissionrdquo and ldquoROSCrdquo there was possible benefit of standard dose epinephrine compared to placebo
Dallas 2015
Draft Treatment Recommendations
For paediatrics in cardiac arrest we suggest no change in the current approach
Therefore no change in the current practice of using vasopressors for paediatric cardiac arrest
Strength of evidence is very low with very serious downgrades in quality assessment for inconsistency indirectness imprecision and risk of bias
Dallas 2015Knowledge Gaps
If adult studies suggest that vasopressor administration is associated with improved ROSC but worse survival to hospital discharge and neurological outcome then prospective studies of placebo vs epinephrinevasopressors for paediatric cardiac arrest would be indicated
Are there selected resuscitation circumstances (eg pulmonary hypertension myocarditis imminent ECPR rescue) where the administration of vasopressors is not indicated
Dallas 2015Next Steps
Task force discussion ndash TR not appropriate and needs better wordsmithing proposal below
There is insufficient evidence of benefit or harm from using no vasopressors compared to any vasopressors to treat infants and children in cardiac arrest
Until specific studies of this question We suggest providers continue to use epinephrine for pediatric cardiac arrest as per their current council-specific practice
Dallas 2015
Proposed Consensus on Science statements
For the important outcome of ldquoROSCrdquo we have identified very low quality evidence (downgraded for indirectness imprecision inconsistency and high risk of bias) from two pediatric out of hospital case series observational studies including 74 patients suggesting uncertain benefit (Enright 2012 336 amp Diekmann 1995 901) (Pooled unadjusted OR 67 95 CI 15 to 297)
Note (See Adult PICO question 788)For all critical and important outcomes we reviewed and considered a single underpowered ADULT out-of-hospital cardiac arrest RCT that provided very low quality evidence (downgraded for extreme indirectness imprecision and risk of bias) comparing Standard Dose Epinephrine to placebo (Jacobs 2011 1138) For the critical outcome ldquogood neurological outcomerdquo and important outcome of ldquosurvival to dischargerdquo there was uncertain benefit or harm of standard dose epinephrine compared to placebo For the important outcomes of ldquoSurvival to Hospital Admissionrdquo and ldquoROSCrdquo there was possible benefit of standard dose epinephrine compared to placebo
Dallas 2015
Draft Treatment Recommendations
For paediatrics in cardiac arrest we suggest no change in the current approach
Therefore no change in the current practice of using vasopressors for paediatric cardiac arrest
Strength of evidence is very low with very serious downgrades in quality assessment for inconsistency indirectness imprecision and risk of bias
Dallas 2015Knowledge Gaps
If adult studies suggest that vasopressor administration is associated with improved ROSC but worse survival to hospital discharge and neurological outcome then prospective studies of placebo vs epinephrinevasopressors for paediatric cardiac arrest would be indicated
Are there selected resuscitation circumstances (eg pulmonary hypertension myocarditis imminent ECPR rescue) where the administration of vasopressors is not indicated
Dallas 2015Next Steps
Task force discussion ndash TR not appropriate and needs better wordsmithing proposal below
There is insufficient evidence of benefit or harm from using no vasopressors compared to any vasopressors to treat infants and children in cardiac arrest
Until specific studies of this question We suggest providers continue to use epinephrine for pediatric cardiac arrest as per their current council-specific practice
Dallas 2015
Draft Treatment Recommendations
For paediatrics in cardiac arrest we suggest no change in the current approach
Therefore no change in the current practice of using vasopressors for paediatric cardiac arrest
Strength of evidence is very low with very serious downgrades in quality assessment for inconsistency indirectness imprecision and risk of bias
Dallas 2015Knowledge Gaps
If adult studies suggest that vasopressor administration is associated with improved ROSC but worse survival to hospital discharge and neurological outcome then prospective studies of placebo vs epinephrinevasopressors for paediatric cardiac arrest would be indicated
Are there selected resuscitation circumstances (eg pulmonary hypertension myocarditis imminent ECPR rescue) where the administration of vasopressors is not indicated
Dallas 2015Next Steps
Task force discussion ndash TR not appropriate and needs better wordsmithing proposal below
There is insufficient evidence of benefit or harm from using no vasopressors compared to any vasopressors to treat infants and children in cardiac arrest
Until specific studies of this question We suggest providers continue to use epinephrine for pediatric cardiac arrest as per their current council-specific practice
Dallas 2015Knowledge Gaps
If adult studies suggest that vasopressor administration is associated with improved ROSC but worse survival to hospital discharge and neurological outcome then prospective studies of placebo vs epinephrinevasopressors for paediatric cardiac arrest would be indicated
Are there selected resuscitation circumstances (eg pulmonary hypertension myocarditis imminent ECPR rescue) where the administration of vasopressors is not indicated
Dallas 2015Next Steps
Task force discussion ndash TR not appropriate and needs better wordsmithing proposal below
There is insufficient evidence of benefit or harm from using no vasopressors compared to any vasopressors to treat infants and children in cardiac arrest
Until specific studies of this question We suggest providers continue to use epinephrine for pediatric cardiac arrest as per their current council-specific practice
Dallas 2015Next Steps
Task force discussion ndash TR not appropriate and needs better wordsmithing proposal below
There is insufficient evidence of benefit or harm from using no vasopressors compared to any vasopressors to treat infants and children in cardiac arrest
Until specific studies of this question We suggest providers continue to use epinephrine for pediatric cardiac arrest as per their current council-specific practice
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