Resuscitating the macro- vs. microcirculation in septic shock.

PURPOSE OF REVIEW: This review summarizes current literature about the relationships between macro and microcirculation and their practical clinical implications in children with septic shock. RECENT FINDINGS: Current evidence from experimental and clinical observational studies in children and adults with septic shock reveals that the response to treatment and resuscitation is widely variable. Furthermore, there is a loss of hemodynamic coherence, as resuscitation-induced improvement in macrocirculation (systemic hemodynamic parameters) does not necessarily result in a parallel improvement in the microcirculation. Therefore, patient-tailored monitoring is essential in order to adjust treatment requirements during resuscitation in septic shock. Optimal monitoring must integrate macrocirculation (heart rate, blood pressure, cardiac output, and ultrasound images), microcirculation (videomicroscopy parameters and capillary refill time) and cellular metabolism (lactic acid, central venous blood oxygen saturation, and difference of central venous to arterial carbon dioxide partial pressure). SUMMARY: There is a dire need for high-quality studies to assess the relationships between macrocirculation, microcirculation and tissue metabolism in children with septic shock. The development of reliable and readily available microcirculation and tissue perfusion biomarkers (other than lactic acid) is also necessary to improve monitoring and treatment adjustment in such patients.

Early detection of ocular lesions in critically ill children: Testing an ocular assessment scale.

OBJECTIVE: There is scarcity of data on the incidence and factors associated with the occurrence of ocular lesions in critically ill children. The objective was to test the applicability and utility of an ocular assessment scale and to identify risk factors of ocular lesions. DESIGN: Prospective observational study. SETTING: A tertiary care medical-surgical Paediatric Intensive Care Unit. SAMPLE: 194 children without previous ocular disease who stayed in the Paediatric Intensive Care Unit for more than 48 h. INTERVENTIONS: An ocular lesions risk scale was designed including risk factors lagophthalmos, eye dryness, conjunctival hyperemia, slow blinking, intubation, sedation, relaxation, face mask and hemodynamic instability. Patients were classified as high-, medium-, and low-risk patients. Corneal lesions were examined by fluorescein staining according to their risk and were confirmed by an ophthalmologist. RESULTS: 76 patients were examined with fluorescein staining. Thirty-two ocular lesions were detected by nursing staff, 26 confirmed by the ophthalmologist. 53.6% of the high-risk patients developed a corneal lesion. Univariate analysis revealed an association between ocular damage and all factors included in the scale, except for face mask. In the multivariate analysis, ocular lesions were associated with lagophthalmos, hyperemia, invasive mechanical ventilation and inotropic support. CONCLUSIONS: The scale was useful to detect corneal lesions in critically ill children. The identification of risk factors will enable the development of measures to reduce the incidence of ocular lesions. RELEVANCE FOR CLINICAL PRACTICE: A new, non-validated scale allowed staff to detect eye injuries, study this problem and improve future prevention.

Protocolo de tratamiento con polietilenglicol 3350 con electrolitos para el estreñimiento en el niño crítico / Protocol for treatment of constipation with polyethylene glycol 3350 plus electrolytes in critically ill children

Introducción y objetivos: Ningún estudio ha analizado la efectividad del tratamiento del estreñimiento en niños críticamente enfermos. El objetivo de este estudio fue evaluar la implementación, la eficacia y la seguridad de un protocolo de tratamiento con polietilenglicol 3350 con electrolitos (PEG 3350+E) para el estreñimiento en niños en estado crítico. Métodos: Estudio prospectivo unicéntrico, incluyendo niños que ingresaron en cuidados intensivos pediátricos durante más de 72h y que desarrollaron estreñimiento. Se excluyeron los niños con trastornos o afecciones gastrointestinales previas. Los pacientes fueron tratados con enemas rectales o con PEG 3350+E oral a criterio del médico tratante. Se compararon variables clínicas, demográficas y efectos secundarios (diarrea, distensión abdominal y desequilibrio electrolítico). Resultados: Se estudiaron 56 pacientes de 48,2±11,9 meses de edad, siendo el 55,4% varones. Cuarenta y cuatro pacientes (78,6%) fueron tratados con PEG 3350+E y 12 pacientes (21,4%) con enemas rectales. El porcentaje de efectividad del PEG 3350+E (79,5%) fue mayor que el de los enemas (58,3%), pero la diferencia no fue estadísticamente significativa (p=0,151). No existieron diferencias significativas en ninguno de los efectos secundarios entre los 2 grupos. El PEG 3350+E fue más efectivo en los niños menores de 2 años (100%) que en los mayores de esa edad (65,4%), p<0,01, sin diferencias significativas en la aparición de efectos secundarios. Conclusiones: El tratamiento del estreñimiento en los niños en estado crítico con PEG 3350+E es eficaz y tiene pocos efectos secundarios, incluso en niños menores de 2 años. (AU)

Introduction and objectives: No studies have analysed the effectiveness of treatment for constipation in critically ill children. The aim of this study was to assess the implementation, efficacy and safety of a treatment protocol using polyethylene glycol 3350 with electrolytes (PEG 3350+E) for constipation in critically ill children. Methods: We conducted a single-centre prospective study in children admitted to the paediatric intensive care unit for a minimum of 72h and who developed constipation. Children with previous gastrointestinal disorders or diseases were excluded. The patients were treated with rectal enemas or with the oral PEG 3350+E protocol at the discretion of the treating physician. We compared clinical and demographic variables as well as adverse events (diarrhoea, abdominal distension and electrolyte imbalances). Results: The sample included 56 patients with a mean age of 48.2±11.9 months, of who 55.4% were male. Forty-four patients (78.6%) were treated with PEG 3350+E and 12 (21.4%) with rectal enemas. The proportion of patients who responded well to treatment was greater in the PEG 3350+E group (79.5%) compared to the enema group (58.3%), but the difference was not statistically significant (P=.151). There were no significant differences between the groups in any of the adverse effects. Treatment with PEG 3350+E was more effective in children aged less than 2 years (100%) compared to older children (100% vs. 65.4%; P<.01), with no significant differences in the development of adverse events. Conclusions: The PEG 3350+E treatment protocol for constipation in critically ill children was effective and associated with few adverse events, even in children aged less than 2 years. (AU)

Protocol for treatment of constipation with polyethylene glycol 3350 plus electrolytes in critically ill children.

INTRODUCTION AND OBJECTIVES: No studies have analysed the effectiveness of treatment for constipation in critically ill children. The aim of this study was to assess the implementation, efficacy and safety of a treatment protocol using polyethylene glycol 3350 with electrolytes (PEG 3350 + E) for constipation in critically ill children. METHODS: We conducted a single-centre prospective study in children admitted to the paediatric intensive care unit for a minimum of 72 h and who developed constipation. Children with previous gastrointestinal disorders or diseases were excluded. The patients were treated with rectal enemas or with the oral PEG 3350 + E protocol at the discretion of the treating physician. We compared clinical and demographic variables as well as adverse events (diarrhoea, abdominal distension and electrolyte imbalances). RESULTS: The sample included 56 patients with a mean age of 48.2 ±â€¯11.9 months, of who 55.4% were male. Forty-four patients (78.6%) were treated with PEG 3350 + E and 12 (21.4%) with rectal enemas. The proportion of patients that responded well to treatment was greater in the PEG 3350 + E group (79.5%) compared to the enema group (58.3%), but the difference was not statistically significant (P = .151). There were no significant differences between the groups in any of the adverse effects. Treatment with PEG 3350 + E was more effective in children aged less than 2 years (100%) compared to older children (100% vs 65.4%; P < .01), with no significant differences in the development of adverse events. CONCLUSIONS: The PEG 3350 + E treatment protocol for constipation in critically ill children was effective and associated with few adverse events, even in children aged less than 2 years.

Volumetric capnography and return of spontaneous circulation in an experimental model of pediatric asphyxial cardiac arrest.

A secondary analysis of a randomized study was performed to study the relationship between volumetric capnography (VCAP) and arterial CO2 partial pressure (PCO2) during cardiopulmonary resuscitation (CPR) and to analyze the ability of these parameters to predict the return of spontaneous circulation (ROSC) in a pediatric animal model of asphyxial cardiac arrest (CA). Asphyxial CA was induced by sedation, muscle relaxation and extubation. CPR was started 2 min after CA occurred. Airway management was performed with early endotracheal intubation or bag-mask ventilation, according to randomization group. CPR was continued until ROSC or 24 min of resuscitation. End-tidal carbon dioxide (EtCO2), CO2 production (VCO2), and EtCO2/VCO2/kg ratio were continuously recorded. Seventy-nine piglets were included, 26 (32.9%) of whom achieved ROSC. EtCO2 was the best predictor of ROSC (AUC 0.72, p < 0.01 and optimal cutoff point of 21.6 mmHg). No statistical differences were obtained regarding VCO2, VCO2/kg and EtCO2/VCO2/kg ratios. VCO2 and VCO2/kg showed an inverse correlation with PCO2, with a higher correlation coefficient as resuscitation progressed. EtCO2 also had an inverse correlation with PCO2 from minute 18 to 24 of resuscitation. Our findings suggest that EtCO2 is the best VCAP-derived parameter for predicting ROSC. EtCO2 and VCO2 showed an inverse correlation with PCO2. Therefore, these parameters are not adequate to measure ventilation during CPR.

Prevalence, Risk Factors and Impact of Nutrition Interruptions in Critically Ill Children.

Background: Enteral nutrition interruptions (ENI) are prevalent in the pediatric intensive care unit (PICU), but there is little evidence of their characteristics. Methods: This is a cross-sectional multicenter study including critically ill children on enteral nutrition. ENIs were classified as PICU procedures, procedures performed outside the PICU (PPOP), feeding intolerance and other criteria. The number and features of ENIs were collected. Results: A total of 75 children were enrolled. There were 41 interruptions affecting 37.3% of the patients with a median duration of 5 ± 9.4 h. The most common reason for ENI was PPOP (41.5%), followed by other criteria. Interruptions were considered preventable in 24.4% of the cases, but only eight were compensated. ENIs were more prevalent among children with cardiac disease (p = 0.047), higher PRISM (p = 0.047) and longer PICU stay (p = 0.035). There was association between PRISM and total interruption time (p = 0.02) and lower caloric intake (p = 0.035). Patients with respiratory illness (p = 0.022) and on noninvasive ventilation (p = 0,028) had fewer ENIs. ENI total time was associated with lower caloric (p = 0.001) and protein (p = 0.02) intake. Conclusions: ENIs are prevalent in PICU, especially in children with higher PRISM, longer PICU stays and cardiac disease, and result in lower caloric and protein intake.

Evaluation of tracheal intubations in a paediatric intensive care unit.

INTRODUCTION: Tracheal intubation is a frequent procedure in paediatric intensive care units (PICUs) that carries a risk of complications that can increase morbidity and mortality. PATIENTS AND METHODS: Prospective, longitudinal, observational study in patients intubated in a level III PICU between January and December 2020. We analysed the risk factors associated with failed intubation and adverse events. RESULTS: The analysis included 48 intubations. The most frequent indication for intubation was hypoxaemic respiratory failure (25%). The first attempt was successful in 60.4% of intubations, without differences between procedures performed by staff physicians and resident physicians (62.5% vs 56.3%; P = .759). Difficulty in bag-mask ventilation was associated with failed intubation in the first attempt (P = .028). Adverse events occurred in 12.5% of intubations, and severe events in 8.3%, including 1 case of cardiac arrest, 2 cases of severe hypotension and 1 of oesophageal intubation with delayed recognition. None of the patients died. Making multiple attempts was significantly associated with adverse events (P < .002). Systematic preparation of the procedure with cognitive aids and role allocation was independently associated with a lower incidence of adverse events. CONCLUSIONS: In critically ill children, first-attempt intubation failure is common and associated with difficulty in bag-mask ventilation. A significant percentage of intubations may result in serious adverse events. The implementation of intubation protocols could decrease the incidence of adverse events.

Evaluación de las intubaciones endotraqueales en una unidad de cuidados intensivos pediátricos / Evaluation of tracheal intubations in a paediatric intensive care unit

Introducción: La intubación traqueal es un procedimiento frecuente en las unidades de cuidados intensivos pediátricos con riesgo de complicaciones que pueden aumentar la morbimortalidad. Pacientes y métodos: Estudio descriptivo y analítico de una cohorte prospectiva que incluye a los pacientes intubados en una unidad de cuidados intensivos pediátricos de tercer nivel entre enero y diciembre de 2020, analizando los factores asociados con el fracaso de intubación y los efectos adversos. Resultados: Se analizaron 48 intubaciones. La indicación más frecuente fue el fallo respiratorio hipoxémico (25%). El primer intento de intubación fue exitoso en el 60,4%, sin diferencias entre los médicos adjuntos y los residentes (62,5 vs. 56,3%; p=0,759). La dificultad en la ventilación con bolsa y mascarilla se asoció con el fracaso del primer intento de intubación (p=0,028). Se objetivaron eventos adversos en un 12,5% de las intubaciones, siendo graves en un 8,3% de los casos, incluyendo una parada cardiorrespiratoria, 2 casos de hipotensión grave y una intubación esofágica detectada de forma tardía. Ninguno de los pacientes falleció. Los intentos múltiples de intubación se asociaron significativamente con la aparición de eventos adversos (p<0,002). La preparación sistemática del procedimiento con ayudas cognitivas y asignación de los papeles del equipo se relacionó de forma independiente con un menor número de eventos adversos. Conclusiones: El éxito en el primer intento de intubación en niños en estado crítico es bajo y se relaciona con la dificultad de ventilación con bolsa y mascarilla. En un porcentaje significativo pueden presentar efectos adversos graves. La utilización de protocolos puede disminuir el número de eventos adversos. (AU)

Introduction: Tracheal intubation is a frequent procedure in paediatric intensive care units that carries a risk of complications that can increase morbidity and mortality. Patients and methods: Prospective, longitudinal, observational study in patients intubated in a level iii paediatric intensive care unit between January and December 2020. We analysed the risk factors associated with failed intubation and adverse events. Results: The analysis included 48 intubations. The most frequent indication for intubation was hypoxaemic respiratory failure (25%). The first attempt was successful in 60.4% of intubations, without differences between procedures performed by staff physicians and resident physicians (62.5 vs. 56.3%; P=.759). Difficulty in bag-mask ventilation was associated with failed intubation in the first attempt (P=.028). Adverse events occurred in 12.5% of intubations, and severe events in 8.3%, including one case of cardiac arrest, 2 cases of severe hypotension and one of oesophageal intubation with delayed recognition. None of the patients died. Making multiple attempts was significantly associated with adverse events (P<.002). Systematic preparation of the procedure with cognitive aids and role allocation was independently associated with a lower incidence of adverse events. Conclusions: In critically ill children, first-attempt intubation failure is common and associated with difficulty in bag-mask ventilation. A significant percentage of intubations may result in serious adverse events. The implementation of intubation protocols could decrease the incidence of adverse events. (AU)

Early vs late enteral nutrition in pediatric intensive care unit: Barriers, benefits, and complications.

BACKGROUND: This study aimed to define the existing barriers for early enteral nutrition (EEN) in critically ill children and to analyze the differences in nutrient supply, complications, and outcomes between EEN and late EN (LEN). METHODS: This is a secondary analysis of a multicenter observational, prospective study including critically ill children receiving EN. Variables analyzed included demographic and anthropometric features, caloric and nutrient supply, outcomes, and complications according to the EN onset. Patients were classified into two groups according to the start of EN: 24-EEN vs EN started after 24 h (24-LEN) and 48-EEN vs EN started after 48 h (48-LEN). RESULTS: Sixty-eight children were enrolled; 22.1% received 24-EEN, and 67.6% received 48-EEN. EN was most frequently delayed in patients older than 12 months, in patients with cardiac disease, and in those requiring mechanical ventilation (MV). Children in the 24-EEN group had shorter duration of MV compared with those in the 24-LEN group (P = 0.04). The 48-EEN group received a higher caloric intake (P = 0.04), reached the caloric target earlier (P < 0.01), and had lower incidence of constipation (P = 0.01) than the 48-LEN group. There was a positive correlation between the time required to reach the maximum caloric intake and the length of pediatric intensive care stay (r = 0.46; P < 0.01). CONCLUSION: EEN may improve nutrient delivery, reduce time on MV, and prevent constipation in critically ill children. No relevant differences between 24-EEN and 48-EEN were found. Cardiac disease, MV, and age older than 12 months were risk factors associated with LEN.

Evaluation and Treatment of Pain in Fetuses, Neonates and Children.

The perception of pain is individual and differs between children and adults. The structures required to feel pain are developed at 24 weeks of gestation. However, pain assessment is complicated, especially in neonates, infants and preschool-age children. Clinical scales adapted to age are the most used methods for assessing and monitoring the degree of pain in children. They evaluate several behavioral and/or physiological parameters related to pain. Some monitors detect the physiological changes that occur in association with painful stimuli, but they do not yet have a clear clinical use. Multimodal analgesia is recommended for pain treatment with non-pharmacological and pharmacological interventions. It is necessary to establish pharmacotherapeutic protocols for analgesia adjusted to the acute or chronic, type and intensity of pain, as well as age. The most used analgesics in children are paracetamol, ibuprofen, dipyrone, opioids (morphine and fentanyl) and local anesthetics. Patient-controlled analgesia is an adequate alternative for adolescent and older children in specific situations, such as after surgery. In patients with severe or persistent pain, it is very important to consult with specific pain services.

ESPNIC clinical practice guidelines: intravenous maintenance fluid therapy in acute and critically ill children- a systematic review and meta-analysis.

PURPOSE: Intravenous maintenance fluid therapy (IV-MFT) prescribing in acute and critically ill children is very variable among pediatric health care professionals. In order to provide up to date IV-MFT guidelines, the European Society of Pediatric and Neonatal Intensive Care (ESPNIC) undertook a systematic review to answer the following five main questions about IV-MFT: (i) the indications for use (ii) the role of isotonic fluid (iii) the role of balanced solutions (iv) IV fluid composition (calcium, magnesium, potassium, glucose and micronutrients) and v) and the optimal amount of fluid. METHODS: A multidisciplinary expert group within ESPNIC conducted this systematic review using the Scottish Intercollegiate Guidelines Network (SIGN) grading method. Five databases were searched for studies that answered these questions, in acute and critically children (from 37 weeks gestational age to 18 years), published until November 2020. The quality of evidence and risk of bias were assessed, and meta-analyses were undertaken when appropriate. A series of recommendations was derived and voted on by the expert group to achieve consensus through two voting rounds. RESULTS: 56 papers met the inclusion criteria, and 16 recommendations were produced. Outcome reporting was inconsistent among studies. Recommendations generated were based on a heterogeneous level of evidence, but consensus within the expert group was high. "Strong consensus" was reached for 11/16 (69%) and "consensus" for 5/16 (31%) of the recommendations. CONCLUSIONS: Key recommendations are to use isotonic balanced solutions providing glucose to restrict IV-MFT infusion volumes in most hospitalized children and to regularly monitor plasma electrolyte levels, serum glucose and fluid balance.

Formación en reanimación cardiopulmonar pediátrica en los grados de Medicina y Enfermería en las universidades españolas / Training in pediatric cardiopulmonary resuscitation in the Medicine and Nursing degrees in Spanish universities

Objetivos: Conocer la docencia en reanimación cardiopulmonar (RCP) pediátrica en las universidades españolas.Material y métodos.Se envió una encuesta a los responsables de pediatría de las universidades españolas.Resultados.Se recibieron 35 respuestas de Medicina y 18 de Enfermería. Existió una gran diversidad en la docencia de la RCP y su duración. En muchos casos, la duración de la formación en RCP es insuficiente.Conclusiones.Es necesario establecer unos requisitos de formación obligatoria en RCP pediátrica para los grados de Medicina y Enfermería. (AU)

Aims: To analyse the education in pediatric cardiopulmonary resuscitation (CPR) in the universities in Spain.Material and methods.A survey was sent to those responsible for Pediatrics at the Spanish universities.Results.35 responses from Medicine and 18 from Nursing were received). There was a great diversity in CPR teaching and duration. In many cases, the duration of the training is insufficient.Conclusions.It is necessary to establish mandatory training requirements in pediatric CPR for Medicine and Nursing degrees. (AU)

Doppler ultrasound in the assessment of renal perfusion before and during continuous kidney replacement therapy in the pediatric intensive care unit.

BACKGROUND: This study aimed to assess observer variability and describe renal resistive index (RRI) and pulsatility index (PI) before and after onset of continuous kidney replacement therapy (CKRT). A secondary objective was to correlate Doppler ultrasound findings with those from direct measurement of renal blood flow (RBF). METHODS: This is a prospective observational study in hemodynamically stable Maryland piglets with and without acute kidney injury (AKI) and in hemodynamically unstable critically ill children requiring CKRT. Doppler-based RRI and PI were assessed for each subject. Measurements were made by two different operators (pediatric intensivists) before and after CKRT onset. RESULTS: Observer variability assessment in the measurement of RRI and PI rendered a moderate correlation for both RRI (ICC 0.65, IQR 0.51-0.76) and PI (ICC 0.63, IQR 0.47-0.75). RRI and PI showed no correlation with RBF or urine output. Baseline RRI and PI were normal in control piglets [RRI 0.68 (SD 0.02), PI 1.25 (SD 0.09)] and those with AKI [RRI 0.68 (SD 0.03), PI 1.20 (SD 0.13)]. Baseline RRI and PI were elevated in critically ill children (RRI 0.85, PI 2.0). PI and RRI did not change with CKRT in any study group. CONCLUSIONS: Observer variability between inexperienced pediatric intensivists was comparable with that between senior and junior operators. Doppler-based calculations did not correlate with invasive measurements of RBF. RRI and PI were normal in hemodynamically stable piglets with and without AKI. RRI and PI were high in hemodynamically unstable patients requiring CKRT. RRI and PI did not change after CKRT onset, despite changes in hemodynamic status. A higher resolution version of the Graphical abstract is available as Supplementary information.

Evaluation of Pediatric Immediate Life Support Courses by the Students.

A retrospective analysis was performed of 1637 questionnaires among students of immediate pediatric life support (IPLS) courses. All theory and practice classes and organization and methods received an average score higher than 8.5 except for the schedule and time devoted to developing contents. All parameters evaluating instructors' skills received a score higher than 9. Participants requested more time to practice and for course adaptation to their specific professionals needs. IPLS courses are highly valued by students. The duration of IPLS practice sessions should be increased and the course should be adapted to the specific professional needs of participants.

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

OBJECTIVES: To analyse the 2020 international and European recommendations for Paediatric cardiopulmonary resuscitation (CPR), highlighting the most important changes and propose lines of development in Spain. METHODS: Critical analysis of the paediatric cardiopulmonary resuscitation recommendations of the European Resuscitation Council. RESULTS: The most relevant changes in the CPR recommendations for 2020 are in basic CPR the possibility of activating the emergency system after performing the five rescue ventilations with the mobile phone on loudspeaker, and in advanced CPR, bag ventilation between two rescuers if possible, the administration of epinephrine as soon as a vascular access is obtained, the increase in the respiratory rate in intubated children between 10 and 25 bpm according to their age and the importance of controlling the quality and coordination of CPR. In CPR training, the importance of training non-technical skills such as teamwork, leadership and communication and frequent training to reinforce and maintain competencies is highlighted. CONCLUSIONS: It is essential that training in Paediatric CPR in Spain follows the same recommendations and is carried out with a common methodology, adapted to the characteristics of health care and the needs of the students. The Spanish Paediatric and Neonatal Cardiopulmonary Resuscitation Group should coordinate this process, but the active participation of all paediatricians and health professionals who care for children is also essential.

Novedades en las recomendaciones de reanimación cardiopulmonar pediátrica y líneas de desarrollo en España / Novelties in the paediatric cardiopulmonary resuscitation recommendations and lines of development in Spain

Objetivos: Analizar las recomendaciones internacionales y europeas de reanimación cardiopulmonar (RCP) pediátrica del 2020, resaltar los cambios más importantes y plantear líneas de desarrollo en España. Métodos: Análisis crítico de las recomendaciones de RCP pediátrica del European Resuscitation Council. Resultados: Los cambios más relevantes en las recomendaciones de RCP del año 2020 son: en la RCP básica, la posibilidad de activar el sistema de emergencias tras realizar las 5 ventilaciones de rescate con el teléfono móvil en altavoz, y en la RCP avanzada, la ventilación con bolsa entre 2 reanimadores si es posible, la administración de adrenalina en cuanto se canaliza un acceso vascular en los ritmos no desfibrilables, el aumento de la frecuencia respiratoria en los niños intubados entre 10 y 25rpm de acuerdo a su edad y la importancia de controlar la calidad y coordinación de la RCP. En la formación en RCP se destaca la importancia de la formación de las habilidades no técnicas como el trabajo en equipo, liderazgo y la comunicación, y el entrenamiento frecuente para reforzar y mantener las competencias. Conclusiones: Es esencial que la formación en RCP pediátrica en España siga las mismas recomendaciones y se realice con una metodología común, adaptada a las características de la atención sanitaria y las necesidades de los alumnos. El Grupo Español de Reanimación Cardiopulmonar Pediátrica y Neonatal debe coordinar este proceso, pero es esencial la participación activa de todos los pediatras y profesionales sanitarios que atienden a los niños. (AU)

Objectives: To analyse the 2020 international and European recommendations for paediatric cardiopulmonary resuscitation (CPR), highlight the most important changes and propose lines of development in Spain. Methods: Critical analysis of the paediatric cardiopulmonary resuscitation recommendations of the European Resuscitation Council. Results: The most relevant changes in the CPR recommendations for 2020 are in basic CPR the possibility of activating the emergency system after performing the five rescue ventilations with the mobile phone on loudspeaker, and in advanced CPR, bag ventilation between two rescuers if possible, the administration of epinephrine as soon as a vascular access is obtained, the increase in the respiratory rate in intubated children between 10 and 25bpm according to their age and the importance of controlling the quality and coordination of CPR. In CPR training, the importance of training non-technical skills such as teamwork, leadership and communication and frequent training to reinforce and maintain competencies is highlighted. Conclusions: It is essential that training in paediatric CPR in Spain follows the same recommendations and is carried out with a common methodology, adapted to the characteristics of health care and the needs of the students. The Spanish Paediatric and Neonatal Cardiopulmonary Resuscitation Group should coordinate this process, but the active participation of all paediatricians and health professionals who care for children is also essential. (AU)