Novelties in the pediatric cardiopulmonary resuscitation recommendations and lines of development in Spain 夽

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AnalesdePediatría96(2022)146.e1---146.e11

www.analesdepediatria.org

SPANISH ASSOCIATION OF PAEDIATRICS

Novelties in the pediatric cardiopulmonary resuscitation recommendations and lines of development in Spain ^夽

Jesús López-Herce

^a,^∗

, Ignacio Manrique

^b

, Custodio Calvo

^c

, Antonio Rodríguez

^d

,

Angel Carrillo

^e

, Valero Sebastián

^f

, Jimena del Castillo

^g

, en nombre del Grupo Espa˜ nol de RCP Pediátrica y Neonatal

¹

aServiciodeCuidadosIntensivosPediátricos,HospitalGeneralUniversitarioGregorioMara˜nóndeMadrid,Institutode

investigaciónsanitariadelHospitalGregorioMarañón,FacultaddeMedicina,UniversidadComplutensedeMadrid,GrupoEspañol deReanimaciónCardiopulmonarPediátricayNeonatal,ReddeSaludMaternoinfantil(SAMIDII).RETICSfinanciadaporelPNI+D+i 2013-2016,ISCIII-SubdirecciónGeneraldeEvaluaciónyFomentodelaInvestigaciónyelFondoEuropeodeDesarrolloRegional (FEDER)ref:RD16/0022/0007,GrupoEspañoldeReanimaciónCardiopulmonarPediátricayNeonatal

bInstitutoValencianodePediatría,GrupoEspa˜noldeReanimaciónCardiopulmonarPediátricayNeonatal

cGrupoEspa˜noldeReanimaciónCardiopulmonarPediátricayNeonatal

dÁreadePediatría,ServiciodeCríticos,IntermediosyUrgenciasPediátricas,HospitalClínicoUniversitariodeSantiagode Compostela,GrupodeInvestigaciónCLINURSID,DepartamentodeEnfermería,UniversidaddeSantiagodeCompostela,Instituto deInvestigacióndeSantiago(IDIS),ReddeSaludMaternoinfantil(SAMIDII),RETICSfinanciadaporelPNI+D+i2013-2016,ISCIII- SubdirecciónGeneraldeEvaluaciónyFomentodelaInvestigaciónyelFondoEuropeodeDesarrolloRegional(FEDER)ref:

RD16/0022/0007,GrupoEspa˜noldeReanimaciónCardiopulmonarPediátricayNeonatal

eGrupoEspa˜noldeReanimaciónCardiopulmonarPediátricayNeonatal

fCentrodeSaludFuentedeSanLuis,Valencia;GrupoEspa˜noldeReanimaciónCardiopulmonarPediátricayNeonatal

gServiciodeCuidadosIntensivosPediátricos,HospitalGeneralUniversitarioGregorioMara˜nóndeMadrid,Institutode

investigaciónsanitariadelHospitalGregorioMarañón,GrupoEspañoldeReanimaciónCardiopulmonarPediátricayNeonatal,Red deSaludMaternoinfantil(SAMIDII).RETICSfinanciadaporelPNI+D+i2013-2016,ISCIII-SubdirecciónGeneraldeEvaluacióny FomentodelaInvestigaciónyelFondoEuropeodeDesarrolloRegional(FEDER)ref:RD16/0022/0007,GrupoEspañolde ReanimaciónCardiopulmonarPediátricayNeonatal

Received20May2021;accepted28May2021 Availableonline17February2022

KEYWORDS Resuscitation;

Paediatric resuscitation;

Abstract

Objectives:Toanalyse the2020internationalandEuropeanrecommendationsforPaediatric cardiopulmonaryresuscitation(CPR),highlightingthemostimportantchangesandproposelines ofdevelopmentinSpain.

夽 Pleasecitethisarticleas:López-HerceJ,ManriqueI,CalvoC,RodríguezA,CarrilloA,SebastiánV,etal.Novedadesenlasrecomenda- cionesdereanimacióncardiopulmonarpediátricaylineasdedesarrolloenEspa˜na.AnPediatr.2022;96:146---146.

∗Correspondingauthor.

E-mailaddress:[email protected](J.López-Herce).

1 ThenamesoftheSpanishPediatricandNeonatalCPRGrouparepresentedinAppendixA.

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Cardiacarrest;

Basiclifesupport;

Advancedlife support;

Medicaleducation

Methods:Criticalanalysisofthepaediatriccardiopulmonaryresuscitationrecommendationsof theEuropeanResuscitationCouncil.

Results: ThemostrelevantchangesintheCPRrecommendationsfor2020areinbasicCPRthe possibilityofactivatingtheemergencysystemafterperformingthefiverescueventilationswith themobilephoneonloudspeaker,andinadvancedCPR,bagventilationbetweentworescuers if possible, theadministration ofepinephrineassoon asavascularaccess isobtained, the increaseintherespiratoryrateinintubatedchildrenbetween10and25bpmaccordingtotheir ageandtheimportanceofcontrollingthequalityandcoordinationofCPR.InCPRtraining,the importanceoftrainingnon-technicalskillssuchasteamwork,leadershipandcommunication andfrequenttrainingtoreinforceandmaintaincompetenciesishighlighted.

Conclusions: Itisessential thattraining inPaediatric CPRinSpainfollows thesamerecom- mendationsandiscarriedoutwithacommonmethodology,adaptedtothecharacteristicsof health careandtheneeds ofthestudents.The SpanishPaediatric andNeonatalCardiopul- monaryResuscitationGroupshouldcoordinatethisprocess,buttheactiveparticipationofall paediatriciansandhealthprofessionalswhocareforchildrenisalsoessential.

4.0/).

PALABRASCLAVE Reanimación cardiopulmonar;

Reanimación cardiopulmonar pediátrica;

Paradacardiaca;

Reanimación cardiopulmonar básica;

Reanimación cardiopulmonar avanzada;

Educaciónmédica

Novedadesenlasrecomendacionesdereanimacióncardiopulmonarpediátricay lineasdedesarrolloenEspa˜na

Resumen

Objetivos: Analizarlasrecomendacionesinternacionalesyeuropeasdereanimacióncardiopul- monar(RCP) pediátricadel2020,resaltarloscambiosmásimportantesyplantearlíneasde desarrolloenEspa˜na.

Métodos: Análisis críticodelasrecomendacionesdereanimacióncardiopulmonar pediátrica delEuropeanResuscitationCouncil.

Resultados: Los cambios más relevantes enlas recomendacionesde RCPdel a˜no 2020son:

en la RCPbásica la posibilidaddeactivar elsistemade emergenciastras realizarlascinco ventilacionesderescateconelteléfonomóvilenaltavoz,yenlaRCPavanzadalaventilación conbolsaentredosreanimadoressiesposible,laadministracióndeadrenalinaencuantose canalizaunaccesovascular,elaumentodelafrecuenciarespiratoriaenlosni˜nosintubados entre10y25rpmdeacuerdoasuedadylaimportanciadecontrolarlacalidadycoordinación delaRCP.EnlaformaciónenRCPsedestacalaimportanciadelaformacióndelashabilidadesno técnicascomoeltrabajoenequipo,liderazgoylacomunicaciónyelentrenamientofrecuente parareforzarymantenerlascompetencias.

Conclusiones: Es esencial que la formación en RCP Pediátrica en España siga las mismas recomendacionesyserealiceconunametodologíacomún,adaptadaalascaracterísticasdela atenciónsanitariaylasnecesidadesdelosalumnos.ElGrupoEspañoldeReanimaciónCardiopul- monar Pediátricay Neonataldebecoordinar esteproceso,peroes esencialla participación activadetodoslospediatrasyprofesionalessanitariosqueatiendenalosniños.

Introduction

Cardiac arrest(CA)continuestobeanimportant causeof mortalityand impairment(chiefly neurologic)in children, although in recent decades the outcomes of cardiopulmonary resuscitation (CPR) have improved significantly.^1,2 EducationandtrainingonCPRofhealthcareworkersandthe generalpopulationis oneofthekeyfactorsfor increasing survivalfreeofsequelaeinchildrenthatexperienceCA.

The aim of thisarticle is to analysethe main international andEuropean guidelines for paediatric life support (PLS)in2020,^3,4highlightinganyrelevantchangesfromthe

2015 guidelines,^5,6 and to make them available topaedi- atriciansandthegeneralpopulation inSpain.TheSpanish PLSguidelineshavebeenadaptedfromtheguidelinesofthe EuropeanResuscitationCouncil(ERC).^7,8

Guidelinereviewprocess

The International Liaison Committee on Resuscitation (ILCOR)usedtopublishtheConsensusonSciencewithTreat- mentRecommendations(CoSTR)every5years.Since2015, theapproachchanged, andrather thanupdating therec- ommendationsevery5years,theCommitteeinstitutedan

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Figure1 Assessmentandstabilizationofchildrenatriskofcardiacarrest.

ongoingprocessinwhichreviewsofspecificsubjectswere madecontinuouslyand asummaryof allthereviewswith publicationofnewrecommendationsevery5years.Thefirst ILCOR recommendations developed throughthis approach werepublishedin2020³andwerefollowedbythepublica-

tionoftheERCguidelinesbasedonthem⁴andthespecific recommendations for CPR ofthe AmericanHeart Associa- tion(AHA).⁹ Werecommendreadingthefulltextof these recommendations.⁴

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Figure2 Paediatricbasiclifesupportalgorithm.

Prevention of cardiac arrest

⁴

The PLS guidelines of the ERC published in 2021 have changedtheapproachcomparedtopreviouseditions,plac- inggreater emphasisontheclinical managementof some of themain clinical scenariosin whichthere isrisk of CA (respiratoryinsufficiency, status asthmaticus,anaphylaxis, shock,statusepilepticus,electrolytedisorders,hyperther- mia)thaninthemanagementofCAperse.⁴Thisreviewof themanagementofurgentconditionsisnotcoveredinthe ILCORCoSTR 2020³anddoesnotentailsignificantchanges relativetopreviousrecommendations:

Management of the child at risk of CA. The ERC recommends use of the paediatric assessment triangle or a similar tool for initial evaluation and to implement a structured assessment and intervention protocol fol- lowing theABCDEsequence----A(airway),B(breathing), C (circulation),D (disability,neurologic impairment),E (exposure)----performingfrequentre-evaluations(Fig.1).

Septic shock. Fluid volume expansion is not recommended in afebrile children that do not present with shock. It is only recommended in thecase of absolute orrelativehypovolaemia(septicoranaphylacticshock).

We recommend administration of crystalloid or colloid boluses (10−20 mL/kg) withsubsequent reassessment, andrepeatedfluidboluses,upto40−60mL/kg,maybe neededinthefirsthouroftreatment,unlessthepatient

developssignsoffluidoverload.Treatmentwithvasoac- tiveandinotropicdrugs mustbetailoredtothepatho- physiology of each patient and adjusted based onthe clinicalresponse.Administrationofstress-dosecorticos- teroidsmaybeconsideredinchildrenwithsepticshock thatdonotrespondtofluidtherapyorvasoactivedrugs.

Volume expansion in haemorrhagic shock secondary to trauma. Although thereis noevidence in children, we suggestexpansionwithreducedandcontrolledvolumes insteadoflargevolumesofcrystalloids.

Bradycardia(heartrate<60bpm).Inthecaseofbrady- cardiawithadequateperipheralperfusion,contemplate administrationofatropine.Inthecaseofaheartrateof lessthan60bpmandpoorperfusion,securetheairway and establish adequate ventilation and, if the patient does not improve, initiate chest compressions and administeradrenaline.Transthoracicpacingisindicated inthecase ofbradycardiasecondary tocompleteheart blockorabnormalfunctionofthesinusnode,butisnot effectiveinthecaseofasystole.

Paediatric basic life support

⁴

TheEuropeanrecommendationsforbasicPLSmaintainthe ABCapproach(airway,breathingandchestcompressions)in theCPRsequence.⁴Themainchangesare:

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Figure3 Paediatricforeignbodyairwayobstructionalgorithm.

Activation of medical emergencysystem.⁴ In the 2015 recommendations, after delivering the first 5 rescue breaths, the rescuer proceeded to assess for signs of life and checking the pulse.^5,6 In the 2020 European recommendations, after delivery of the first 5 rescue breaths, in the case of a lone rescuer with a mobile phone with speaker function, the next step is to activate the hands-free option to call emergency medicalservices (EMS)while continuing todeliverCPR (Fig.2).Ifamobilephoneisnotavailable,thebystander shouldcontinueCPRfor1minbeforeleavingthechildto contactEMS.TherescuershouldonlycallEMSfirstincase ofwitnessingsuddenlossofconsciousnessofsuspected cardiacorigin,followedbyinitiationofCPR,asthechild couldneeddefibrillation.Ifthereismorethanoneres- cuer, one should start CPR immediately while another callsforhelp(Fig.2).

Assessmentofbreathing.Layrescuersmayassessbreath- ingbasedsolelyonthepresenceorabsenceofbreathing movements(Figs.3and4).

Assessment ofCPR effectiveness.To minimisethetime without chest compressions, it is recommended that CPRcontinuewithoutinterruptionunlessthereareclear signs of spontaneous circulation (movement, cough) (Figs.5and6).

Paediatric advanced life support

⁴

TheABCsequenceusedinpaediatricbasiclifesupportis alsousedinpaediatricadvancedlifesupport.

Teamwork.Therecommendationsemphasisetheneedof efficientteamwork to allow simultaneousperformance ofdifferentmanoeuvresandreducetheinterruptionin deliveryofchestcompressionsandventilation.

Airwayandventilation.Ifpossible,2rescuersshouldopen theairwaymanuallyanddeliverbag-valve-maskventila- tiontoensureadequateventilation.Incaseofintubation withacuffedendotrachealtube,maintainthecuffpres- sureunder20---25cmH2O.

Respiratory rate. If the patient is not intubated, ventilation coordinated with chest compressions is still recommended(2breathsper15chestcompressions).In intubatedpatients,coordinationofventilationandchest compressions continues to not be recommended, and insteaditis recommendedthattherespiratoryrate be increased basedon the lower limit of normal for age:

<1 year, 25 bpm, 1---8 years, 20 bpm; 8---12 years, 15 bpm;>12 years,10 bpm.DuringCPR, useaconcentra- tionofinspiredoxygenof100%forventilation.Inpatients alreadyonmechanicalventilation,itispossibletomain- tainitputtingtheventilatorinvolume-controlledmode, disablingtriggersandalarms.

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Figure4 PaediatricadvancedCPRalgorithm.

Adrenaline. The most significant change is the recommendation toadminister adrenaline (the samedose of 0.01mg/kgof1:10000adrenaline)assoonaspossible, thatis,oncevascularaccessisestablished,withoutwait- ingtocomplete3minofchestcompressionsandrescue breathsinpatientswithnonshockablerhythms.

Severebradycardia.Emphasisontheneedtotreatsevere bradycardiaintheabsenceofvitalsigns,evenifthereis adetectablepulse.

Defibrillation.Thestandardenergydoseof4J/kgisstill recommendedtostartdefibrillation,introducingthepos- sibility of increasingthe dose to8 J/kgin arrhythmias refractory tomorethan 5shocks,never exceedingthe recommended dose for adults. Defibrillation withself- adhesive padsispreferred.Ifunavailable,itis possible

touse paddles withpreformed gel pads, and charging should bedone oncethe paddles are onthe pads and in direct contact with the chest of the patient, con- trary to the previous recommendation of charging the paddlesawayfromthepatienttominimisethepausein chestcompressions.Arationaleforthischangewasnot specified.

Pharmacological treatment of shockable rhythms. The 2015 recommendations hold, with administration of adrenalineandamiodarone(dose of5mg/kgtoamax- imumof300mgfortheinitialdoseand150mgforthe seconddose)afterthethirdandfifthshocks.Lidocaine canbesubstitutedforamiodaroneatadoseof1mg/kg.

Afterthefifth shock, adrenaline shouldbegivenevery 3−5min.

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Figure5 AdvancedCPRalgorithm,non-shockablerhythms.

Quality of CPR. Capnography is not recommended to assess the qualityof chest compressions,but it is recommended toverifyendotracheal tube placement and for earlydetectionofreturnofspontaneouscirculation (ROSC).Theguidelinesdonotestablishatargetinvasive bloodpressurevalueforadvancedPLS.

Ultrasound. Point-of-care ultrasound may be useful to identifyreversible causesof CA,butitsuse shouldnot interferewithdeliveryofCPR andshouldbelimitedto rescuerswithsubstantialexperienceinthetechnique.

Table1presentsthedosageofthedrugsusedinPLS.

Post-resuscitation care

^4,10

The ABCD sequence is recommendedto establish care prioritiesandforongoingassessment.

Oxygenationobjectives.Childrenthatexperiencedshort- lived CA and immediately recover consciousness and spontaneousbreathingshouldreceiveoxygentherapyas neededtoachieveaSpO₂greaterthan94%.Inintubated patients, after the ROSC, the fractionof inspired oxygen(FiO₂)shouldbesetat100%untilthearterialoxygen saturation (SaO2)or partialpressureof oxygenin arterial blood (PaO₂) can be measured reliably. From that point, theFiO2 shouldbetitratedtoachieveaSaO2 of 94%---98% andaPaO₂of75---100 mmHg.Bothhypoxemia (PaO₂ <60mmHg)andhyperoxaemia mustbeavoided.

In patients with carbon monoxide poisoning or severe

anaemia, in who peripheral oxygen saturation (SpO2) readings are not as reliable, higher FiO₂ settings and morefrequentarterialbloodgasmeasurementsarerec- ommended.

Ventilation objectives. It is recommended that ventilation starts with respiratory rate and tidal volume settingsinthenormalrangeforageinalung-protection strategy. Initially, ventilator parameters should be set to achieve an arterial PaCO₂ in the normal range (35−45mmHg).Subsequently,capnographycanbeused toguideadjustmentofmechanicalventilationaslongas its correspondence with the PaCO2 is verifiedat regu- larintervals.Inchildrenwithchronicpulmonarydisease or congenital heart disease with single-ventricle physiology, the goal should be to restore previous PaCO2

values.Patientsunder therapeutic hypothermia,which may cause hypocapnia, and patients receiving ventila- tionformanagementof increasedintracranialpressure requiremorefrequentmeasurementofPaCO2.

Bloodpressure(BP).Continuousinvasive BPmonitoring isrecommendedtoachieveasystolicBPatorabovethe medianforage.Fluidsandinotropicorvasopressordrugs shouldbe given in theminimum necessary amounts to reachthistarget.

Neuroprotection.Inpatientsthatremaincomatoseafter ROSC,activecontroloftemperaturetomaintainacen- traltemperatureof37.5^◦Corlessisrecommended.

Prognosis. Althoughseveral factorsareassociated with the long-term outcome of CA, there is no single one

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Figure6 AdvancedCPRalgorithm,shockablerhythms.

thatcanbeusedinisolationtoestablishtheprognosis.

Thecombineduseofmultiplevariablesisrecommended, includingbiomarkersandneuroimagingfeatures.

Ethical considerations

^4,11

Anticipatorycare planningandshareddecisionmaking.

AlthoughCAisasuddenevent,inmanycasesitispossible topredictitsrisk,soitis recommendedthatproviders facilitate care planningahead of time,providing clear informationandrespectingtheautonomyofthepatient andlegalguardians,includingdecisionsregardingresus- citation(whethertoinitiateCPRor notintheeventof CA) amongother treatment decisions.Todoso,health care professionals need to hone their communication skills, take into accountthevalues andpreferences of patients and their families, involve the latter in the shareddecision-makingprocessand,whenappropriate, implement withdrawal or withholding of life-sustaining treatment protocolswhileprovidingpalliative careand psychologicalsupport.

Criteria to initiate and terminate CPR. Resuscitation should be perceived as a treatment based oncriteria.

Some criteria areunequivocal, such asany risk to the rescuer, thepresence of clear signsof deathor a previous agreementnot to initiateCPR. Others can guide decision-making,suchaspersistentasystoleafter20min ofadvancedCPRinabsenceofareversiblecause,unwit- nessed CA withan initial non-shockable rhythm witha

verypoorprognosisorexistingevidencethatCPRwould notfitthe valuesorpreferencesof thepatient.Inany case,thereasonstonotinitiate,notprolongortotermi- nateCPRshouldbeclearlydocumented.

Research ethics. There is a clear need to obtain sci- entific evidence to improve the outcomes of CA. This objectiveinvolves adaptingconsentprocedures,review by research ethics and establishment of good clinical practice guidelinesin additionto involving community stakeholdersandhealth careinstitutionsinthedesign, funding,performanceanddisseminationofresearch.

Training

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Education and training in the management of CA are keytoimproveoutcomes.Therefore,currentguidelines emphasise the need to improve the efficiency of edu- cational interventions, with adaptation of trainings to specific target groups, integrating new approaches in trainingandprovidingtrainingatregularintervals.

Professionalsthatworkwithchildrenshouldgetinvolved.

It is recommended that training be delivered by instructors experienced in the use of specific materials (traditional CPR manikins, quality-control devices, advancedsimulators,virtual/augmentedrealitysystems, etc.)andwithqualificationsonnon-technicalskillssuch as teamwork, leadership and communication. We recommend frequent refresher trainings and updating of skills. As for the format and content of the courses,

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AnalesdePediatría96(2022)146.e1---146.e11 Table1 DrugsusedinpaediatricCPR.

Drug Dose Preparation Route Indication

Adrenaline 0.01mg/kg DilutedinPSS(1+9):

0.1mL/kg

IV,IO,ETbolus CA Max:1mg ET:0.1mg/kg,undiluted

Adenosine 1st:0.2mg/kg Followingimmediatelywith 5−10mLPSSwash

IV,IObolus SVT

Max:6mg 2nd:0.4mg/kg Max:12mg

Amiodarone 5mg/kg Pure IV,IO RefractoryVForPVT

Max:300mg BOLUSINCA SVTorVT

SLOWRATEINALL OTHERCASES

Atropine 0.02mg/kg 0.2mL/kg IV,IO Vagalbradycardia

Max:1mg BOLUS

Bicarbonate 1mEq/kg InsolutionwithPSS:

2mL/kg

IV,IO RefractoryCA

Max:50mEq BOLUS

Calcium 0.2mEq/kg= Calciumgluconate10%

0.4mL/kg

IV,IOatslowrate Hypocalcaemia, hyperkaliaemia, hypermagnesemia Max:10mEq Calciumchloride10%

0.2mL/kg,insolution

Calciumchannelblocker intoxication

Glucose 0.2−0.4g/kg Glucose10%:2−4mL/kg IV,IO Documentedhypoglycaemia Bolus

Lidocaine 1mg/kg Undiluted IV,IO RefractoryVForPVT

Max:100mg Bolus

Fluids 20mL/kg PSS IV,IO PEA

Rapidrate Hypovolaemia

Magnesium 50mg/kg Undiluted IV,IO PolymorphicVTwithtorsades

depointes Bolus

CA,cardiacarrest;CPR,cardiopulmonaryresuscitation;ET,endotracheal;IO,intraosseous;IV,intravenous;Max,maximumdose;PEA, pulselesselectricalactivity;PSS,physiologicalsalinesolution;PVT,pulselessventriculartachycardia;SVT,supraventriculartachycardia;

VF,ventricularfibrillation;VT,ventriculartachycardia.

werecommendlimitingin-persontheoreticalknowledge sessions, usingremoteeducationplatformsinstead(for autonomous or instructor-guided learning), and study preceding in-person practical skill simulation activities followedbyinteractivediscussionsessions.

Trainingofadults.Everycitizenshouldknowhowtoacti- vatethechainofsurvivalandinitiatebasicCPR.Training should includepaediatric CPRand theresponsetofor- eignbodyairwayobstruction(FBAO).Trainingsshouldbe deliveredbyinstructorsexperiencedinteachinglaypeo- pleusingmethodologyadaptedtothespecificneedsof thestudents,andrefreshertrainingsshouldbeconducted atleastonceayear.

Trainingofchildren.TheERChaslaunchedtheKidsSave Livesinitiativewiththegoalofhavingallchildrenlearn howtoactivate the chainof survival andinitiateCPR.

Trainingcontentsmustbeadaptedtotheageandphys- icaldevelopmentofchildren.Itmustbeincludedinthe school curriculum and be delivered by teachers previ- ously trained in basic life support and using materials designedspecificallyforthepurpose.Theultimateobjec- tiveistoensurethatfutureadultsknowhowtorespond

appropriatelytoCAinordertoimprovesurvivalfreeof neurologicsequelae.

Conclusion and future perspectives

The 2020 guidelinesfor paediatric and neonatal life support, including the international ILCOR recommendations andthe ERC recommendations in Europe, have notintro- ducedsignificant changesintheresuscitation sequenceor techniques. The most significant changes in PLS are the earlyadministrationofadrenalineassoonasvascularaccess is established and the increase in respiratory rate during CPRto10---25bpm,dependingonage,followingintubation.

AnotheraspecttoconsideristheadaptationofCPRinthe contextoftheCOVID-19pandemic.¹³

Recommendations areincreasingly placingemphasis on qualitycontrolin CPRandthetrainingofrescuersinnon- technical skills, such as leadership, communication and teamwork.

Oureffortstoimprovepaediatricresuscitationoutcomes mustextendtoeverysetting,startingwithtrainingthegen-

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eralpopulationinthepreventionofCAandpaediatricCPR skills,inwhichpaediatriciansplayanessentialroleincol- laborationwitheducators.

At the care setting level, the participation of paediatricians is key in the development of plans to prevent and manage CA in children and providing training in PLS to health care workers based on the specific needs of each care setting. The use of scales to assess the risk of CA and the creation of rapid response teams areboth recommended.

When it comes toeducation, each facility should plan delivery of structuredCPR trainings toevery professional andatdifferentlevels(basic,intermediateandadvanced) based on their activity. The Spanish Group on Paediatric and Neonatal Cardiopulmonary Resuscitation recommends that the theoretical education that precedes intermediate and advanced CPR trainings include not only how to identify and assess CA risk, but also how to manage the most common conditions associated with a risk of CA.

Another important goal is to develop a continuing education programme based on short practice sessions and scenario simulations withemphasis onassessment of CPR quality and development of coordination and teamwork skills.

Teaching standardised CPR guidelines facilitates learning,improvesCPRoutcomesanddecreasestheprobability of errors. Therefore, it would be best if all PLS training in Spain was basedon the same guidelinesand delivered appliedasimilarmethodology,adaptedtothespecificchar- acteristics of health care and needs of students in the country. The primary objective of Spanish Group on Pae- diatricandNeonatalCardiopulmonaryResuscitationshould be to coordinate this process,¹⁴ and another essential aspect is the active participation of all paediatricians and health care professionals involved in the care of children.

Data availability

Datawillbemadeavailableonrequest.

Our open-access data is available via Zenodo (https://doi.org/10.5281/zenodo.5794358) but we were unabletolinkthisdatasetinthe\

Appendix A. Members of the Spanish Group on Paediatric and Neonatal Cardiopulmonary Resuscitation

none- Jesús López-Herce. Paediatric Intensive Care Department. Hospital General Universitario Grego- rio Mara˜nón de Madrid. Instituto de Investigación Sanitaria del Hospital Gregorio Mara˜nón. School of Medicine. Universidad Complutense de Madrid.

SpanishGrouponPaediatricandNeonatalCardiopul- monaryResuscitation.Mother-ChildHealthResearch Network (SAMID II). RETICS funded by theNational PlanforR+D+I2013---2016,ISCIII-GeneralViceDirec- torateofResearchEvaluationandPromotionandthe European Regional Development Fund (FEDER) Ref:

RD16/0022/0007. Spanish Group on Paediatric and NeonatalCardiopulmonaryResuscitation.

none- IgnacioManrique.InstitutoValencianodePediatría.

SpanishGrouponPaediatricandNeonatalCardiopul- monaryResuscitation.

none- Custodio Calvo. Spanish Group on Paediatric and NeonatalCardiopulmonaryResuscitation.

none- Antonio Rodríguez. Section of Paediatrics, Depart- ment of Padiatric Intensive, Intermediate and Emergency Care. Hospital Clínico Universitario de Santiago de Compostela. Clinical Nursing Research Group (CLINURSID), Department of Nursing, Uni- versidad de Santiago de Compostela. Instituto de Investigación de Santiago (IDIS). SAMID II Research Network. RETICS funded by the National Plan for R + D+I 2013---2016, ISCIII- General Vice Direc- torateofResearchEvaluationandPromotionandthe European RegionalDevelopment Fund (FEDER) Ref:

RD16/0022/0007. Spanish Group on Paediatric and NeonatalCardiopulmonaryResuscitation.

none- Ángel Carrillo. Spanish Group on Paediatric and NeonatalCardiopulmonaryResuscitation.

none- ValeroSebastián.CentrodeSaludFuentedeSanLuis.

Valencia.SpanishGroup onPaediatricandNeonatal CardiopulmonaryResuscitation

none- JimenadelCastillo.DepartmentofPaediatricInten- sive Care. Hospital General Universitario Gregorio Mara˜nón deMadrid.InstitutodeInvestigación Sani- tariadelHospital GregorioMara˜nón.SpanishGroup onPaediatricandNeonatalCardiopulmonary Resus- citation.SAMIDIIResearchNetwork.RETICSfunded bythe National Plan for R+ D+I 2013---2016, ISCIII- GeneralViceDirectorateofResearchEvaluationand Promotionand theEuropean RegionalDevelopment Fund (FEDER) Ref:RD16/0022/0007.Spanish Group onPaediatricandNeonatalCardiopulmonary Resus- citation.

none- EvaCivantos.Centro deSaluddeBarranco Grande.

Tenerife.SpanishGrouponPaediatricandNeonatal CardiopulmonaryResuscitation.

none- Eva Suárez.Centro de Salud Integrado Burriana II.

Castellon.SpanishGrouponPaediatricandNeonatal CardiopulmonaryResuscitation.

none- SaraPons.DepartmentofPaediatrics.HospitalDoc- torPeset.Valencia.SpanishGrouponPaediatricand NeonatalCardiopulmonaryResuscitation.

none- GonzaloZeballos.DepartmentofNeonatology.Hos- pital General Universitario Gregorio Mara˜nón de Madrid.InstitutodeInvestigaciónSanitariadelHos- pitalGregorioMara˜nón.SpanishGrouponPaediatric andNeonatalCardiopulmonaryResuscitation.

none- María José Aguayo. Hospital Universitario Virgen delRocío,Seville. Spanish GrouponPaediatricand NeonatalCardiopulmonaryResuscitation.

Appendix B. Supplementary data

Supplementarymaterialrelatedtothisarticlecanbefound, in the online version, at doi:https://doi.org/10.1016/

j.anpede.2021.05.011.

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