Recommended guidelines for uniform reporting of pediatric advanced life support: the pediatric Utstein style. A statement for healthcare professionals from a task force of the American Academy of Pediatrics, the American Heart Association, and the European Resuscitation Council.

This consensus document is an attempt to provide an organized method of reporting pediatric ALS data in out-of-hospital, emergency department, and in-hospital settings. For this methodology to gain wide acceptance, the task force encourages development of a common data set for both adult and pediatric ALS interventions. In addition, every effort should be made to ensure that consistent definitions are used in all age groups. As health care changes, we will all be challenged to document the effectiveness of what we currently do and show how new interventions or methods of treatment improve outcome and/or reduce cost. Only through collaborative research will we obtain the necessary data. For these reasons, and to improve the quality of care and patient outcomes, it is the hope of the task force that clinical researchers will follow the recommendations in this document. It is recognized that further refinements of this statement will be needed; these recommendations will improve only when researchers, clinicians, and EMS personnel use them, work with them, and modify them. Suggestions, emendations, and other comments aimed at improving the reporting of pediatric resuscitation should be sent to Arno Zaritsky, MD, Eastern Virginia Medical School, Children's Hospital of The King's Daughter, Division of Critical Care Medicine, 601 Children's Lane, Norfolk, VA 23507.

The most important changes in the international ECC and CPR guidelines 2000.

Many people involved with resuscitation have specific interests and enthusiasm. They will review the new guidelines to see how their favorite interventions fared. This essay lists a number of the new guidelines that merit special attention: support for family presence at resuscitations, pronouncing death at the scene rather than after futile transport efforts, honoring advance directives, comparable effectiveness of bag-mask ventilation versus tracheal intubation, revision of compression rates and compression-ventilation ratios, and devices to confirm tracheal intubation and prevent tube dislodgment. Even more important are the new principles and concepts that the International Guidelines 2000 endorse: international guideline science, international guideline development, evidence-based guidelines, training by objectives, expanded scope of ECC to first aid and periarrest conditions, avoidance of false-negative (type II) errors, video-mediated instruction, and a philosophy to 'do no harm.' The number and magnitude of these new guidelines reflect the dynamic nature of resuscitation at the start of the 21st century. There is great optimism that these new and revised guidelines will help achieve our ultimate objective. This objective is to be ready when fate brings some lives to a premature end. If we are, we can restore more of these people to a high-quality life, ready for many more years of living.

Guidelines based on the principle 'First, do no harm'. New guidelines on tracheal tube confirmation and prevention of dislodgment.

In summary, this editorial and the one on pulse check point out another area in which a total reliance on evidence-based guidelines amy do our patients a disservice. The debate over dropping the pulse check hinged less on the strength of the evidence and more on the widespread clinical principle of fear of false-negative errors. The discussion of secondary confirmation of tracheal tube placement also lacks a strong base of evidence that identifies the one best technique of tube confirmation for patients with a pulse versus those without a pulse. The principles of the zero-risk intervention and first, do no harm come into play in this situation. We must deal with the growing awareness of the fact that tracheal intubation is not only a potentially lethal intervention but now is also a confirmed lethal intervention, and at a much higher death rate than has ever been suspected. Factors that contribute to the transformation of the tracheal tube from a life-saving to a death-causing intervention are being identified by honest and open researchers. National societies in emergency medicine are responding appropriately. We strongly recommend shifting from making an evidence-based recommendation to instead making a principle-based recommendation--killing our patients is unacceptable; we must act on the widespread concept regarding errors in medicine. We must adopt zero-risk interventions in all possible situations.

Paediatric life support. An advisory statement by the Paediatric Life Support Working Group of the International Liaison Committee on Resuscitation.

This document reflects the deliberations of ILCOR. The epidemiology and outcome of paediatric cardiopulmonary arrest and the priorities, techniques and sequence of paediatric resuscitation assessments and interventions differ from those of adults. The working group identified areas of conflict and controversy in current paediatric basic and advanced life support guidelines, outlined solutions considered and made recommendations by consensus. The working group was surprised by the degree of conformity already existing in current guidelines advocated by the American Heart Association (AHA), the Heart and Stroke Foundation of Canada (HSFC), the European Resuscitation Council (ERC), the Australian Resuscitation Council (ARC), and the Resuscitation Council of Southern Africa (RCSA). Differences are currently based upon local and regional preferences, training networks and customs, rather than scientific controversy. Unresolved issues with potential for future universal application are highlighted. This document does not include a complete list of guidelines for which there is no perceived controversy and the algorithm/decision tree figures presented attempt to follow a common flow of assessments and interventions, in coordination with their adult counterparts. Survival following paediatric prehospital cardiopulmonary arrest occurs in only approximately 3-17% and survivors are often neurologically devastated. Most paediatric resuscitation reports have been retrospective in design and plagued with inconsistent resuscitation definitions and patient inclusion criteria. Careful and thoughtful application of uniform guidelines for reporting outcomes of advanced life support interventions using large, randomized, multicenter and multinational clinical trials are clearly needed. Paediatric advisory statements from ILCOR will, by necessity, be vibrant and evolving guidelines fostered by national and international organizations intent on improving the outcome of resuscitation for infants and children worldwide.

Recommended guidelines for uniform reporting of pediatric advanced life support: the Pediatric Utstein Style. A statement for healthcare professionals from a task force of the American Academy of Pediatrics, the American Heart Association, and the European Resuscitation Council.

This consensus document is an attempt to provide an organized method of reporting pediatric ALS data in out-of-hospital, emergency department, and in-hospital settings. For this methodology to gain wide acceptance, the task force encourages development of a common data set for both adult and pediatric ALS interventions. In addition, every effort should be made to ensure that consistent definitions are used in all age groups. As health care changes, we will all be challenged to document the effectiveness of what we currently do and show how new interventions or methods of treatment improve outcome and/or reduce cost. Only through collaborative research will we obtain the necessary data. For these reasons, and to improve the quality of care and patient outcomes, it is the hope of the task force that clinical researchers will follow the recommendations in this document. It is recognized that further refinements of this statement will be needed; these recommendations will improve only when researchers, clinicians, and EMS personnel use them, work with them, and modify them. Suggestions, recommendations, and other comments aimed at improving the reporting of pediatric resuscitation should be sent to Arno Zaritsky, MD, Eastern Virginia Medical School, Children's Hospital of The King's Daughter, Division of Critical Care Medicine, 601 Children's Lane, Norfolk, VA 23507.

Epidemiology, pathophysiology and clinical presentation of gram-negative sepsis.

OBJECTIVE: To review the epidemiology and pathophysiology of gram-negative sepsis and the new consensus terminology describing the clinical signs of sepsis. DATA SOURCES: Review of the medical literature and compiled data from animal and clinical trials. PARTICIPANTS: Members of the Society of Critical Care Medicine, American College of Chest Physicians and American Association of Critical-Care Nurses with expertise on the subject of sepsis and its complications. RESULTS: Preconference and general sessions were offered at the National Teaching Institutes of the American Association of Critical-Care Nurses, with the goal of clarifying the epidemiology, risk factors and pathophysiology of gram-negative sepsis. In addition, current terminology and new (1992) consensus terminology describing the clinical signs of sepsis were presented. Special emphasis was placed on the role of the healthcare provider in the prevention and recognition of sepsis and the role of the septic mediators in the septic cascade. CONCLUSIONS: If the incidence of sepsis is to be reduced, the healthcare provider must be aware of the risk factors for sepsis and methods of reducing nosocomial infections. A thorough understanding of the role of mediators and consensus terminology used to describe sepsis, severe sepsis, septic shock and multiple organ dysfunction syndrome is necessary to recognize early or progressive signs of sepsis and to initiate state-of-the-art therapy.

Shock in the pediatric patient.

Care of the child in shock requires careful and constant assessment of the child's systemic perfusion. In addition, oxygenation and ventilation must be supported. The child's heart rate must be maintained, since pediatric cardiac output often is directly related to heart rate. The goal of treatment of shock of any origin is to ensure that cardiac output is adequate to provide tissue oxygenation and substrate delivery. This goal is accomplished through careful titration of intravenous fluids to optimize ventricular preload and maximization of ventricular function (often with inotropic or vasodilator support). The child should be kept warm, and careful regulation and evaluation of total fluid intake and output is necessary. Parents should be allowed to remain with the child as much as possible, since this will comfort both the child and the parents. The child should be prepared gently for any painful procedures, and realistic but compassionate communication with the entire family is essential. Through constant assessment and evaluation of patient response to therapy, the nurse is in the best position to detect early signs of compromise and to determine effectiveness of therapy. Therefore, it is imperative that the nurse possess a thorough understanding of the pathophysiology and clinical progression of shock in the child, as well as the rationale and potential complications of management.

Mediator-specific therapies for the systemic inflammatory response syndrome, sepsis, severe sepsis, and septic shock: present and future approaches.

Despite recent advances in critical care and cardiopulmonary support, mortality from septic shock and its complications remains high. Effective therapies are needed to halt the progression of SIRS and the septic cascade prior to development of shock and organ ischemia/dysfunction. Such therapies are directed at prevention of infection/endotoxemia and modulation of mediators. These therapies are the focus of this article.

Postoperative care of the critically ill child.

Postoperative care of the pediatric surgical patient requires knowledge of the signs of cardiorespiratory and neurologic deterioration in the child as well as familiarity with particular postoperative complications associated with various types of surgery. This article briefly reviewed the principles of postoperative care of the critically ill child, and included references for more comprehensive sources of information.