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The European Resuscitation Council (ERC) Paediatric Life Support (PLS) guidelines are based on the 2020 International Consensus on Cardiopulmonary Resuscitation Science with Treatment Recommendations of the International Liaison Committee on Resuscitation (ILCOR). This section provides guidelines on the management of critically ill or injured infants, children and adolescents before, during and after respiratory/cardiac arrest.

Informed by a series of systematic reviews, scoping reviews and evidence updates from the International Liaison Committee on Resuscitation, the 2021 European Resuscitation Council Guidelines present the most up to date evidence-based guidelines for the practice of resuscitation across Europe. The guidelines cover the epidemiology of cardiac arrest; the role that systems play in saving lives, adult basic life support, adult advanced life support, resuscitation in special circumstances, post resuscitation care, first aid, neonatal life support, paediatric life support, ethics and education.

This 2020 International Consensus on Cardiopulmonary Resuscitation and Emergency Cardiovascular Care Science With Treatment Recommendations (CoSTR) for pediatric life support is based on the most extensive evidence evaluation ever performed by the Pediatric Life Support Task Force. Three types of evidence evaluation were used in this review: systematic reviews, scoping reviews, and evidence updates. Per agreement with the evidence evaluation recommendations of the International Liaison Committee on Resuscitation, only systematic reviews could result in a new or revised treatment recommendation. Systematic reviews performed for this 2020 CoSTR for pediatric life support included the topics of sequencing of airway-breaths-compressions versus compressions-airway-breaths in the delivery of pediatric basic life support, the initial timing and dose intervals for epinephrine administration during resuscitation, and the targets for oxygen and carbon dioxide levels in pediatric patients after return of spontaneous circulation. The most controversial topics included the initial timing and dose intervals of epinephrine administration (new treatment recommendations were made) and the administration of fluid for infants and children with septic shock (this latter topic was evaluated by evidence update). All evidence reviews identified the paucity of pediatric data and the need for more research involving resuscitation of infants and children.

BACKGROUND Airway management is a defining skill for anaesthesiologists. Anaesthesiologists must maintain and update these crucial skills throughout their career, but how this is best achieved remains unclear. This study aimed to clarify anaesthesiologists' procedural volume, confidence in airway management and their current and preferred future educational strategies. METHODS A questionnaire was developed consisting of 28 items exploring essential skills in airway management. All anaesthesiologists in the Capital Region of Denmark were invited to participate. RESULTS The response rate was 84% (240/285). Most anaesthesiologists felt competent to a high or very high degree in basic airway management. Anaesthesiologists from anaesthesia felt confident to a significantly higher degree than those working in the intensive care unit (ICU) regarding the practical aspects of airway management in both the anticipated difficult airway (93% vs 73%, P

Aim of the Study: Necrotizing enterocolitis (NEC) is a devastating intestinal disease that mainly affects preterm infants. Despite advancements in neonatal care, mortality of NEC remains high and c...

Tracheal pouches can cause dangerous respiratory problems. This case concerns an occult tracheal pouch in a child, occurring after neonatal repair of esophageal atresia with tracheoesophageal fistula. The pouch caused life-threatening displacements of endotracheal tubes, both during and after intubations. In addition to the tracheal pouch, the child had recurrence of an upper esophageal fistula and severe tracheomalacia which complicated the acute respiratory symptoms. This case reveals possible pitfalls in the care and treatment of patients after esophageal/tracheal surgery. The care and treatment of these children is challenging and may require a multidisciplinary setting and several surgical procedures.

Die Leitlinien des European Resuscitation Council (ERC) zu den lebensrettenden Maßnahmen bei Kindern (Paediatric Life Support, PLS) basieren auf dem 2020 verfassten „International Consensus on Cardiopulmonary Resuscitation Science with Treatment Recommendations“ der ILCOR (International Liaison Committee on Resuscitation). Dieses Kapitel beinhaltet Leitlinien zur Behandlung kritisch kranker oder verletzter Säuglinge, von Kindern und Jugendlichen vor, während und nach einem Atem-Kreislauf-Stillstand.

These European Resuscitation Council Paediatric Life Support (PLS) guidelines, are based on the 2020 International Consensus on Cardiopulmonary Resuscitation Science with Treatment Recommendations. This section provides guidelines on the management of critically ill infants and children, before, during and after cardiac arrest.

Reduced intestinal perfusion is thought to be a part of the pathogenesis in necrotizing enterocolitis (NEC). This study aims to evaluate the intestinal perfusion assessment in NEC-lesions by quantitative fluorescence angiography with indocyanine green (q-ICG) during laparoscopy and open surgery.Thirty-four premature piglets were delivered by cesarean section and fed with parenteral nutrition and increasing infant formula volumes to induce NEC. During surgery, macroscopic NEC-lesions were evaluated using a validated macroscopic scoring system (1-6 for increasing NEC severity). The intestinal perfusion was assessed by q-ICG and quantified with a validated pixel intensity computer algorithm.Significantly higher perfusion values were found in healthy areas of the colon (score 1) compared to those with NEC scores of 4, 5, and 6 (p 0.05). Similarly, in the small intestine, perfusion was higher in the intestine with areas scored 1 compared to scores of 3 and 4 (p 0.05). A cut-off value was found between NEC score of 1-2 vs. 3-4 for the small intestine at 117 and for colon at 107 between NEC scores 12 vs. scores of 36 with an area less than the curve value at 0.9 (p 0.05).q-ICG seems to be a feasible and valuable technique to evaluate the perfusion of tissue with NEC-lesions. We found a cut-off between intestine with scores 1-2 and intestine with NEC scores 3-6 in colon, and NEC score 3-4 in the small intestine.II.

This 2020 International Consensus on Cardiopulmonary Resuscitation and Emergency Cardiovascular Care Science With Treatment Recommendations (CoSTR) for pediatric life support is based on the most extensive evidence evaluation ever performed by the Pediatric Life Support Task Force. Three types of evidence evaluation were used in this review: systematic reviews, scoping reviews, and evidence updates. Per agreement with the evidence evaluation recommendations of the International Liaison Committee on Resuscitation, only systematic reviews could result in a new or revised treatment recommendation. Systematic reviews performed for this 2020 CoSTR for pediatric life support included the topics of sequencing of airway-breaths-compressions versus compressions-airway-breaths in the delivery of pediatric basic life support, the initial timing and dose intervals for epinephrine administration during resuscitation, and the targets for oxygen and carbon dioxide levels in pediatric patients after return of spontaneous circulation. The most controversial topics included the initial timing and dose intervals of epinephrine administration (new treatment recommendations were made) and the administration of fluid for infants and children with septic shock (this latter topic was evaluated by evidence update). All evidence reviews identified the paucity of pediatric data and the need for more research involving resuscitation of infants and children.

BACKGROUND Clonidine is used off-label in children but only limited pediatric pharmacokinetic data are available for intravenously administered clonidine. OBJECTIVES To determine pharmacokinetic parameter estimates of clonidine in healthy children undergoing surgery and to investigate age-related differences. Furthermore, to investigate possible pharmacokinetic differences of clonidine between this group of children and a cohort with cardiac diseases. METHODS In a randomized placebo-controlled trial (The PREVENT AGITATION trial), blood samples for clonidine pharmacokinetic analysis were collected in a proportion of the enrolled patients. Healthy children with ASA score 1-2 in the age-groups 1 to

Complete resection is the treatment of choice for most pediatric brain tumors, but early postoperative MRI for detection of residual tumor may be misleading because of MRI signal changes caused by the operation. PET imaging with amino acid tracers in adults increases the diagnostic accuracy for brain tumors, but the literature in pediatric neurooncology is limited. A hybrid PET/MRI system is highly beneficial in children, reducing the number of scanning procedures, and this is to our knowledge the first larger study using PET/MRI in pediatric neurooncology. We evaluated if additional postoperative 18F-fluoro-ethyl-tyrosine ( 18F-FET) PET in children and adolescents would improve diagnostic accuracy for the detection of residual tumor as compared with MRI alone and would assist clinical management. Methods: Twenty-two patients (7 male; mean age, 9.5 y; range, 0–19 y) were included prospectively and consecutively in the study and had 27 early postoperative 18F-FET PET exams performed preferentially in a hybrid PET/MRI system (NCT03402425). Results: Using follow-up (93%) or reoperation (7%) as the reference standard, PET combined with MRI discriminated tumor from treatment effects with a lesion-based sensitivity/ specificity/accuracy (95% confidence intervals) of 0.73 (0.50–1.00)/ 1.00 (0.74–1.00)/0.87 (0.73–1.00) compared with MRI alone: 0.80 (0.57–1.00)/0.75 (0.53–0.94)/0.77 (0.65–0.90); that is, the specificity for PET/MRI was 1.00 as compared with 0.75 for MRI alone (P 5 0.13). In 11 of 27 cases (41%), results from the 18F-FET PET scans added relevant clinical information, including one scan that directly influenced clinical management because an additional residual tumor site was identified. 18F-FET uptake in reactive changes was frequent (52%), but correct interpretation was possible in all cases. Conclusion: The high specificity for detecting residual tumor suggests that supplementary 18F-FET PET is relevant in cases where reoperation for residual tumor is considered.

Aim: To compare dyad (training in pairs without an instructor) with resource-intensive instructor-led training for laypersons’ paediatric resuscitation skills in a non-inferiority trial and examine cost-effectiveness of the training methods. Methods: In this randomised parallel group non-inferiority trial, 155 dyad and 175 instructor-led laypersons were trained in Basic Life Support and Foreign Body Airway Obstruction Management. Dyads were given instructional videos, hands-on exercises and provided feedback to their partner for 50 min. Instructor-led laypersons trained in groups of six for two hours. Learning were assessed in scenarios immediately after training and, subsequently, at 14 days, 1, and 3 months. Pass rates, cost-effectiveness of producing a competent layperson (passing both tests), and non-inferiority were analysed. Results: Sixty-eight (45.6%) dyad and 130 (74.3%) instructor-led laypersons passed the basic life support test (p < 0.001). For Foreign Body Airway Obstruction Management 77 (54.2%) dyad and 130 (79.3%) for instructor-led laypersons passed (p < 0.001). Skills decreased over three months for both groups. Forty-two (30.4%) dyad and ninety-eight (59.8%) for instructor-led laypersons were competent after training (p < 0.001). The lower effectiveness of dyad training had reduced costs (p < 0.001). For each 10,000 USD allocated to training, dyad training would result in 71 vs. 65 competent laypersons for instructor-led training. Non-inferiority of dyad training could not be established. Conclusion: Instructor-led training was the most effective but also the most expensive training method, making it less cost-effective than dyad training. When the aim is to train for quantity rather than quality, dyad training would be the preferred choice of training method.

Complete resection is the treatment of choice for most pediatric brain tumors, but early postoperative MRI for detection of residual tumor may be misleading because of MRI signal changes caused by the operation. PET imaging with amino acid tracers in adults increases the diagnostic accuracy for brain tumors, but the literature in pediatric neurooncology is limited. A hybrid PET/MRI system is highly beneficial in children, reducing the number of scanning procedures, and this is to our knowledge the first larger study using PET/MRI in pediatric neurooncology. We evaluated if additional postoperative

Background Standardised courses for laypeople in Paediatric Basic Life Support (PBLS) and Foreign Body Airway Obstruction Management (FBAOM) teach essential skills for the initiation of resuscitation by bystanders. Performance assessments are necessary to ensure that skills are acquired. We aimed to examine the validity of developed performance assessments and to determine credible pass/fail standards. Methods Validity evidence was gathered in a standardised simulated setting by testing participants with three different levels of PBLS/FBAOM experience: untrained laypersons, trained laypersons, and lifeguards. Two blinded raters assessed participants’ performance. The reliability of test scores was analysed using generalizability theory, scores were compared across the three groups, and pass/fail-standards were established. Results A total of 33 participants were included. More than two raters and two cases were necessary for PBLS to achieve a reliability coefficient above 0.80, which is considered the minimally acceptable level for high-stakes certification. For FBAOM, two tests or three raters were needed. Assessment scores differed across the three groups for PBLS skills, as well as for FBAOM skills (p

Post-operative agitation (PA) is a common problem (20-70%) in children anaesthetised with sevoflur-ane. Clonidine is widely used off-label in children for several indications, including PA, but the current level of evidence is limited. Our aim is to investigate the impact of prophylactic intravenous (IV) clonidine administered at the end of surgery on the incidence and degree of PA. Furthermore, the pharmacokinetic profile of IV clonidine in children is not well established and our aim is to obtain pharmacokinetic data relating hereto.This is a multicentre, randomised and blinded clinical trial in which we will be enrolling 380 children aged 1-5 years who are planned for anaesthesia with sevoflurane and fentanyl. Inclusion is based on computer-generated randomisation (1:1) and stratified by age and site. The study drug is administered IV approximately 20 min. before the expected completion of surgery (intervention: clonidine 3 µg per kg; placebo: equal quantity of saline).The primary outcome is PA measured on the Watcha scale. The secondary outcomes include post-operative pain relief and adverse effects, including a 30-day follow-up. In total, 40 children will be allocated to drug assay sampling, enabling a compartmental pharmacokinetic analysis.Funded by the participating departments and by two unrestricted scientific grants from the Danish Society of Anaesthesia and Intensive.This study was approved by the Danish Health and Medicines Authority (EudraCT number 2014-001466-10), the Ethics Committee of the Capital Region of Denmark (H-2-2014-072) and registered with Clinicaltrials.gov (NCT02361476).

The prevalence of childhood obesity is increasing. The focus of this review is the special anesthetic considerations regarding the perioperative management of obese children. With obesity the risk of comorbidity such as asthma, obstructive sleep apnea, hypertension, and diabetes increases. The obese child has an increased risk of perioperative complications especially related to airway management and ventilation. There is a significantly increased risk of difficult mask ventilation and perioperative desaturation. Furthermore, obesity has an impact on the pharmacokinetics of most anesthetic drugs. This has important implications on how to estimate the optimal drug dose. This article offers a review of the literature on definition, prevalence and the pathophysiology of childhood obesity and provides suggestions on preanesthetic evaluation, airway management and dosage of the anesthetic drugs in these patients. The authors highlight the need of supplemental studies on various areas of the subject.

AIM: To describe the implementation of a novel first-responder programme in which home care providers equipped with automated external defibrillators (AEDs) were dispatched in parallel with existing emergency medical services in the event of a suspected out-of-hospital cardiac arrest (OHCA).METHODS: We evaluated a one-year prospective study that trained home care providers in performing cardiopulmonary resuscitation (CPR) and using an AED in cases of suspected OHCA. Data were collected from cardiac arrest case files, case files from each provider dispatch and a survey among dispatched providers. The study was conducted in a rural district in Denmark.RESULTS: Home care providers were dispatched to 28 of the 60 OHCAs that occurred in the study period. In ten cases the providers arrived before the ambulance service and subsequently performed CPR. AED analysis was executed in three cases and shock was delivered in one case. For 26 of the 28 cases, the cardiac arrest occurred in a private home. Ninety-five per cent of the providers who had been dispatched to a cardiac arrest reported feeling prepared for managing the initial resuscitation, including use of AED.CONCLUSION: Home care providers are suited to act as first-responders in predominantly rural and residential districts. Future follow-up will allow further evaluation of home care provider arrivals and patient survival.

The incretin hormone, glucose-dependent insulinotropic polypeptide (GIP, previously known as gastric inhibitory polypeptide), is rapidly degraded to the biologically inactive metabolite GIP (3-42) in the circulation, but little is known about the kinetics of the intact hormone and the metabolite and whether differences exist between patients with type 2 diabetes mellitus and healthy subjects. We examined eight type 2 diabetic patients (six men, two women); mean (range) age: 59 (48–69) years; BMI: 31.6 (26.0–37.7) kg/m 2 ; HbA 1C : 9.0 (8.2–13.2) %; fasting plasma glucose (FPG): 10.0 (8.3–13.2) mmol/l and 8 healthy subjects matched for age, gender and BMI. An intravenous bolus injection of GIP (7.5 nmol) was given and venous blood samples were drawn the following 45 minutes. Peak concentrations of total GIP (intact + metabolite, mean ± SEM) and intact GIP (in brackets) were 920 ± 91 (442 ± 52) pmol/l in the type 2 diabetic patients and 775 ± 68 (424 ± 30) pmol/l in the healthy subjects (NS). GIP was eliminated rapidly with the clearance rate for intact GIP being 2.3 ± 0.2 l/min in the type 2 diabetic patients and 2.4 ± 0.2 l/min in the healthy subjects (NS). The volumes of distributions were similar in the two groups and ranged from 8 to 21 l per subject. The primary metabolite, GIP 3-42, generated through the action of dipeptidyl peptidase IV (DPP-IV), was eliminated with a mean half-life of 17.5 and 20.5 min in patients and healthy subjects (NS). Conclusion: Elimination of GIP is similar in obese type 2 diabetic patients and matched healthy subjects. Differences in elimination of GIP and its primary metabolite, therefore, do not seem to contribute to the defective insulinotropic effect of GIP in type 2 diabetes.

The mechanism behind exercise-induced decreases in plasma insulin concentrations was examined in eight healthy young men. In addition, the influence of specific alpha(1)- and alpha(2)-adrenoceptor blockade on glucose kinetics during exercise was studied. To test the hypothesis that exercise-induced decreases in insulin secretion are mediated via alpha(2)-adrenoceptors, all subjects exercised for 60 min on separate occasions under four conditions: with and without alpha(1)-receptor blockade (1 mg prazosin) and with and without or alpha(2)-receptor blockade (15 mg yohimbine). Glucose kinetics were measured using [3-(3)H]glucose. During exercise with alpha(2)-receptor blockade, the insulin concentration initially increased (first 20 min) then decreased, whereas it continually decreased in the corresponding control experiment. The C-peptide concentration did not change during exercise with alpha(2)-receptor blockade but decreased in the control experiment. During exercise with alpha(1)-receptor blockade and corresponding control experiments, insulin and C-peptide levels always decreased. With alpha(1)-receptor blockade, the glucose concentration increased (first 30 min) and then decreased, whereas it slightly decreased in all other experiments. In addition, with alpha(1)-receptor blockade, the glucose rate of appearance (Ra) increased rapidly (because of higher catecholamine concentrations in alpha(1)-receptor blockade versus control) and the glucose rate of disappearance (Rd) was higher compared with control. During exercise with alpha(2)-receptor blockade, the Ra and Rd were always lower compared with control. Therefore, we conclude that exercise-induced decreases in insulin secretion are mediated via alpha(2)-adrenoceptors and that blockade of alpha(1)- and alpha(2)-adrenoceptors during exercise elicits opposite responses in glucose Ra and Rd.

Background: Cardiovascular variables are closely regulated in that they remain relatively stable during minor hemorrhage. We considered that such stability would make these variables less accurate for monitoring a blood loss. In contrast, thoracic electrical impedance would be unlikely to be a regulated variable and could serve as a non-invasive monitor of a volume deficit. Methods: In 10 pigs bled (0–24 ml kg−1) and retransfused (to 28 ml kg−1) during halothane anesthesia, the magnitude of the electrical impedance, cardiovascular, blood gas and temperature variables, atrial natriuretic peptide and near infrared spectroscopy of the leg muscles were recorded. Results: During hemorrhage and retransfusion, the median correlations between changes in the magnitude of the thoracic impedance and the external blood loss ranged from 0.97 to 0.98 with an individual range from 0.80 to 1.0. These correlation coefficients were higher and their ranges were lower than correlations established for any other measured parameter. Conclusion: During hemorrhage and retransfusion in the halothane anesthetized pig, a change in the magnitude of thoracic electrical impedance appears to be an accurate and also non-invasive monitor of a blood volume deficit.

Intensive care of infants below one year of age has been centralized in a paediatric intensive care unit (PICU) related to the neonatal intensive care unit (NICU) at Rigshospitalet, the University Hospital in Copenhagen in eastern Denmark (approximately 2.5 million inhabitants) since 2002. The aim of this paper was to evaluate the experiences from the PICU.A descriptive study including data from the 01.01.2002-31.12.2010-period from all the admissions to the PICU for infants below one year of age fulfilling one of two criteria: 1) born preterm and admitted to the department after 40 weeks of gestational age or 2) born at term and admitted to the department at an age -older than 28 days. Data were registered prospectively including information on primary diagnoses at admission, the need for mechanical ventilation and the duration of mechanical ventilation. Mortality was evaluated in the three year-period 2008-2010 by use of the Paediatric Index of Mortality 2 score (PIM2 score).The nine-year period saw 927 admissions to the PICU and 355 infants received mechanical ventilation (median three days). The PIM2 score was 6.7% and the mortality was 6.7% in the period during which PIM2 score was registered. The incidence of mechanical ventilation due to respiratory failure was 0.74/1,000 infants born in the -region.The experience from the NICU seems to -compensate for a low volume of infants in the PICU. The -incidence of mechanically ventilated infants due to respiratory disease in eastern Denmark is relatively low.Not relevant.Not relevant. The study was not registered, as it is an observational study.

Mastery of paediatric resuscitation is challenged as medical students only face a few seriously ill children during training in paediatric departments. Blended Learning (BL) may increase student's knowledge and Mastery Learning (ML) may increase the skill level. We investigated the current paediatric resuscitation knowledge and skill level and the effect of combining BL and ML for paediatric resuscitation by medical students.

Steen M. Hansen1, Stig Brondum2, Grethe Thomas3, Susanne R. Rasmussen4, Birgitte Kvist5, Anette Christensen6, Charlotte Lyng7, Jan Lindberg6, Torsten L.B. Lauritsen8, Freddy Lippert9, Christian Torp-Pedersen1, Poul A. Hansen6,∗ 1 Department of Health, Science and Technology, Aalborg University, Aalborg, Denmark 2 Hjerteforeningen, Danish Heart Foundation, Copenhagen, Denmark 3 The Danish Foundation TrygFonden, Copenhagen, Denmark 4 KORA, Danish Institute for Local and Regional Government Research, Aarhus, Denmark 5 Department of Health and Nursing, Municipality of Frederikshavn, Northern Region, Denmark 6 Prehospital Care Organization, North Region, Denmark 7 Home Care Organization, Municipality of Frederikshavn, Denmark 8 Department of Anaesthesia, The Juliane Marie Centre, Rigshopitalet, University Hospital of Copenhagen, Copenhagen, Denmark 9 The Emergency Medical Services, Capital Region of Denmark, Denmark

In this review, we discuss anaphylaxis, which is a severe allergic condition with potentially life-threatening symptoms from airways or circulation and often associated with skin symptoms. First-line treatment is intramuscular adrenaline given by autoinjector for rapid administration. Initial dose for children < 25 kg is 0.15 mg and for children ≥ 25 kg and adults 0.3 mg. Repeated smaller doses of adrenaline is to be preferred. Patients with severe anaphylaxis will need an IV access for fluid replacement and supplementary oxygen. Antihistamines and steroids are only second-line treatment after adrenaline administration.