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1. High-quality cardiopulmonary resuscitation (CPR) is the foundation of resuscitation. New data reaffirm the key components of high-quality CPR: providing adequate chest compression rate and depth, minimizing interruptions in CPR, allowing full chest recoil between compressions, and avoiding excessive ventilation. 2. A respiratory rate of 20 to 30 breaths per minute is new for infants and children who are (a) receiving CPR with an advanced airway in place or (b) receiving rescue breathing and have a pulse. 3. For patients with nonshockable rhythms, the earlier epinephrine is administered after CPR initiation, the more likely the patient is to survive. 4. Using a cuffed endotracheal tube decreases the need for endotracheal tube changes. 5. The routine use of cricoid pressure does not reduce the risk ofd regurgitation during bag-mask ventilation and may impede intubation success. 6. For out-of-hospital cardiac arrest, bag-mask ventilation results in the same resuscitation outcomes as advanced airway interventions such as endotracheal intubation. 7. Resuscitation does not end with return of spontaneous circulation (ROSC). Excellent post–cardiac arrest care is critically important to achieving the best patient outcomes. For children who do not regain consciousness after ROSC, this care includes targeted temperature management and continuous electroencephalography monitoring. The prevention and/or treatment of hypotension, hyperoxia or hypoxia, and hypercapnia or hypocapnia is important. 8. After discharge from the hospital, cardiac arrest survivors can have physical, cognitive, and emotional challenges and may need ongoing therapies and interventions. 9. Naloxone can reverse respiratory arrest due to opioid overdose, but there is no evidence that it benefits patients in cardiac arrest. 10. Fluid resuscitation in sepsis is based on patient response and requires frequent reassessment. Balanced crystalloid, unbalanced crystalloid, and colloid fluids are all acceptable for sepsis resuscitation. Epinephrine or norepinephrine infusions are used for fluid-refractory septic shock. More than 20 000 infants and children have a cardiac arrest per year in the …

OBJECTIVE: Pediatric cardiac intensive care units (CICU) should be adept at treating both critical medical and surgical conditions for patients with cardiac disease. There are no case mix adjusted quality metrics specific to medical CICU admissions. We aimed to measure case mix adjusted CICU medical mortality rates and assess variation across CICUs in the Pediatric Cardiac Critical Care Consortium (PC4). DESIGN: Observational analysis SETTING: PC4 clinical registry PATIENTS: All CICU admissions that did not include cardiac surgery. INTERVENTIONS: None MEASUREMENTS AND MAIN RESULTS: The primary endpoint was CICU mortality. Based on multivariable logistic regression accounting for clustering, we created a case mix adjusted model using variables present at CICU admission. Bootstrap resampling (1000 samples) was used for model validation. We calculated a standardized mortality ratio (SMR) for each CICU based on observed-to-expected mortality from the fitted model. A CICU was considered a statistically significant outlier if the 95% confidence interval around the SMR did not cross 1. Of 11,042 consecutive medical admissions from 25 CICUs (8/2014–5/2017) the observed mortality rate was 4.3% (N=479). Final model covariates included age, underweight, prior surgery, time of and reason for CICU admission, high-risk medical diagnosis or comorbidity, mechanical ventilation or ECMO at admission, and pupillary reflex. The c-statistic for the validated model was 0.87 and it was well calibrated. Expected mortality ranged from 2.6–8.3%, reflecting important case mix variation. SMRs ranged from 0.5–1.7 across CICUs. Three CICUs were outliers; two had lower-than-expected (SMR 1) mortality. CONCLUSIONS: We measured case mix adjusted mortality for CICU patients with critical medical conditions, and provide the first report of variation in this quality metric within this patient population across PC4 CICUs. This metric will be used by PC4 CICUs to assess and improve outcomes by identifying high-performing (low-mortality) centers through collaborative learning.