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When we were pediatric residents, it was drilled into our heads: in the NICU, they use NRP; in the PICU, PALS is the norm; and in the cafeteria, ACLS is usually the right choice. These American Heart Association resuscitation guidelines, meant to be tailored to distinct patient populations, seem also to sometimes vary based on geography.

For example, imagine encountering this scenario as a pediatric anesthesiologist: you are emergently called to the bedside of a 3 month-old, 7 kg baby in cardiac arrest who is not intubated. Should your compression to ventilation ratio be 3:1 or 15:2?  Does it matter if the patient is in the NICU vs. the PICU? How is it possible for the same child to receive such diverse care, and is it possible that both are right? Today's Pediatric Anesthesia Article of the Day1 aims to establish a framework for approaching the resuscitation of our most vulnerable and critically ill patients.

Original Article

Sawyer T, McBride ME, Ades A, Kapadia VS, Leone TA, Lakshminrusimha S, Ali N, Marshall S, Schmölzer GM, Kadlec KD, Pusic MV, Bigham BL, Bhanji F, Donoghue AJ, Raymond T, Kamath-Rayne BD, de Caen A. Considerations on the Use of Neonatal and Pediatric Resuscitation Guidelines for Hospitalized Neonates and Infants: On Behalf of the American Heart Association Emergency Cardiovascular Care Committee and the American Academy of Pediatrics. Pediatrics. 2024 Jan 1;153(1):e2023064681. doi: 10.1542/peds.2023-064681. PMID: 38105696.

This article brings into focus a seemingly straightforward, yet crucial topic: when to transition from neonatal resuscitation guidelines to pediatric resuscitation guidelines? While there is little debate about the most appropriate algorithm for a “newly born infant” in the first few seconds of life (Neonatal Resuscitation Program or NRP) or a toddler with bronchiolitis (Pediatric Advanced Life Support or PALS), determining when this transition occurs is more complex.

NRP and PALS differ in several important ways. Let’s start with purpose: NRP is focused on resuscitation and stabilization at birth, and its algorithms are designed to help infants struggling with the transition from in utero to ex utero life. PALS is designed to address diverse causes of cardiac arrest for a wide range of infants, children, and adolescents – including newborns after discharge from the hospital.  But what about the patients who don’t go home in the first few days?

One of the most dramatic differences between the two guidelines is the ratio of compressions to breaths (for patients without an advanced airway in place). NRP recommends a ratio of 3:12,3 while PALS recommends 15:2 for two-rescuer CPR (or 30:2 for one-rescuer, which we don’t routinely use in the hospital).4,5 NRP also prioritizes airway and ventilation prior to chest compressions (the traditional A-B-C approach), unlike PALS which begin with high-quality chest compressions (C-A-B, similar to adult ACLS algorithms). Both of these differences reflect the presumption that in transitioning newly born infants, there is more likely to be a respiratory cause than a primary cardiac cause. 

Other differences between NRP and PALS include epinephrine dosing (0.02 mg/kg in NRP, 0.01 mg/kg in PALS), targeted temperature management guidelines, and the increased total number of algorithms in PALS (based on rhythm, etc) compared with a singular universal algorithm in NRP. And, of course, PALS doesn’t spend much time on umbilical venous access.

While there has never been a head-to-head outcomes comparison between NRP and PALS (and how could there ever be, really?), numerous groups have sought out to answer the question of when to transition from NRP guidelines to PALS guidelines? Some have advocated for a more nuanced approach that takes in to account the chronological and/or gestational age of the patient as well as their physiological derangements. Others have advocated for a more pragmatic approach based on physical location, such as: every child in the cardiac ICU, regardless of age, will be resuscitated via PALS – every child in the NICU, regardless of age, will be resuscitated via NRP.

Several surveys have attempted to provide data on this topic with murky results, finding that most NICUs continue to use a 3:1 compression to ventilation ratios throughout an infant’s hospitalization, regardless of age. In our places (Boston Chidren’s, Children’s Hospital of Philadelphia) this could sometimes be over 6 months of age! Despite the persistence of a 3:1 ratio in older children, the authors found that the diagnostic approaches and treatment plans begin to blend PALS with NRP as newborns grew older or carried more specific diagnoses.6

Interestingly, the NICU at the University of Wisconsin sought to better articulate their approach to resuscitation with a novel approach. Select neonates (> 44 weeks post menstrual age, and those with prior cardiac surgeries or identified arrhythmias) would be treated via the PALS algorithm. These NICU patients would be identified with a sign by their bedspace denoting that they qualified for PALS. As such, the same NICU team could perform either NRP or PALS depending on the specific patient within their NICU. This obviously highlights the need for NICU providers to be certified in both NRP and PALS, but what about pediatric anesthesiologists? Are PAAD readers certified in NRP, PALS, or both?

At the end of the day, as highlighted above we are unlikely to ever see a prospective study to answer these questions. Instead, we encourage familiarity with (if not certification in) NRP guidelines for all who care for neonates and infants, as a shared mental model of what an ideal resuscitation looks like is necessary for any emergency situation. We also propose that the single most important factor in successful newborn resuscitation is having providers that come together to work as a team, with such a shared mental model. Code events, even at high volume, high acuity centers, can be chaotic even under the most ideal circumstances. Having an inter-disciplinary team that is well organized, experienced, and works well together is, without a doubt, critical for good patient outcomes.

Consider your own practice: are you and your colleagues trained in both NRP and PALS? Is there practice in responding to code situations where management guidelines may differ from the typical OR approach? Should cardiac arrest guidelines be distinct in the OR compared to the published NRP or PALS guidelines? We invite you to share your thoughts and comments with Myron (MYasterster@gmail.com) who will feature selected responses in a Friday Reader Response.

PS from Myron: My go to in arrest or really any perioperative crisis is to open the Society for Pediatric Anesthesia’s Pedi Crisis (V2) app on my cellphone. After reading today’s PAAD, I discovered much to my chagrin, that we only provide the PALS guideline recommendations in the app. Going forward should we add NRP guidelines under a tab for neonates? After all we do anesthetize many neonates and knowing the appropriate guidelines makes a lot of sense. I’ll bring this up with Pedicrisis app committee.

References

1.          Sawyer T, McBride ME, Ades A, et al. Considerations on the Use of Neonatal and Pediatric Resuscitation Guidelines for Hospitalized Neonates and Infants: On Behalf of the American Heart Association Emergency Cardiovascular Care Committee and the American Academy of Pediatrics. Pediatrics 2024;153(1) (In eng). DOI: 10.1542/peds.2023-064681.

2.          Weiner GM, Zaichkin J. Updates for the Neonatal Resuscitation Program and Resuscitation Guidelines. Neoreviews 2022;23(4):e238-e249. (In eng). DOI: 10.1542/neo.23-4-e238.

3.          Aziz K, Lee CHC, Escobedo MB, et al. Part 5: Neonatal Resuscitation 2020 American Heart Association Guidelines for Cardiopulmonary Resuscitation and Emergency Cardiovascular Care. Pediatrics 2021;147(Suppl 1) (In eng). DOI: 10.1542/peds.2020-038505E.

4.          Maconochie IK, Aickin R, Hazinski MF, et al. Pediatric Life Support 2020 International Consensus on Cardiopulmonary Resuscitation and Emergency Cardiovascular Care Science With Treatment Recommendations. Pediatrics 2021;147(Suppl 1) (In eng). DOI: 10.1542/peds.2020-038505B.

5.          Topjian AA, Raymond TT, Atkins D, et al. Part 4: Pediatric Basic and Advanced Life Support: 2020 American Heart Association Guidelines for Cardiopulmonary Resuscitation and Emergency Cardiovascular Care. Circulation 2020;142(16_suppl_2):S469-s523. (In eng). DOI: 10.1161/cir.0000000000000901.

6.          Gover A, Levy PT, Zaltsberg-Barak T, et al. Neonatal resuscitation in the NICU; Challenges beyond NRP. Acta paediatrica (Oslo, Norway : 1992) 2021;110(12):3269-3271. (In eng). DOI: 10.1111/apa.16057.

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