Dallas 2015 TFQO: Allan de Caen COI#38 EVREV 1: Melissa Parker COI#259 EVREV 1: Takanari Ikeyama COI#235 Taskforce: Pediatrics Peds 820 : The use of fluids and inotropes in infants & children post ROSC for maintaining BP

Dallas 2015 COI Disclosure EVREV 1 Melissa Parker COI#259 Commercial/industry NIL Potential intellectual conflicts NIL EVREV 2 Takanari Ikeyama COI#235 Commercial/industry Nil Potential intellectual conflicts Nil

Dallas CoSTR Not Reviewed

Dallas 2015 C2015 PICO Population: Infants and children post-ROSC Intervention: Does the use of parenteral fluids and inotropes and/or vasopressors to maintain targeted measures of perfusion i.e. BP Comparison: as compared with not using these interventions Outcomes: change patient satisfaction Survival with Favorable neurological/functional outcome at discharge, 30 days, 60 days, 180 days AND/OR 1 year, Survival to hospital discharge harm to patient?

Dallas 2015 Inclusion/Exclusion & Articles Found Main search topics:, pediatric, post-resuscitation, blood pressure/ hypotension, cardiotonic agents Excluded: abstracts, reviews, case reports, editorials and articles not relevant to the PICO 1814 articles, 3 included RCTs= 0 Observational = 3 Excluded = 1811

Dallas Proposed Treatment Recommendations We suggest to avoid hypotension in children with ROSC after cardiac arrest (OHCA or IHCA) (weak recommendation, very low quality of evidence).

Dallas 2015 Risk of Bias in studies

Dallas 2015 Evidence profile table

Dallas 2015 Evidence profile table

Dallas 2015 Proposed Consensus on Science statements For the CRITICAL outcome of 'survival to hospital discharge with good neurological outcome' we have identified very low quality evidence from one observational multicentre retrospective cohort study of 367 children who experienced IHCA or OHCA and for whom neurologic status at discharge was available (Topjian, 2014, 1518) (downgraded for risk of bias, indirectness, and imprecision). The unadjusted Odds Ratio (OR) for survival with good neurologic outcome for children exposed to hypotension post ROSC is 0.65 [95% CI: ; p=0.043].

Dallas 2015 Proposed Consensus on Science statements For the CRITICAL outcome of 'patient satisfaction' we have identified no evidence. For the IMPORTANT outcome of 'survival to hospital discharge' we have identified very low quality evidence from three observational multicentre retrospective cohort studies involving a total of 615 children who experienced OHCA or IHCA (Topjian, 2014, 1518), non-traumatic OHCA (Lin, 2010, 410), or traumatic OHCA (Lin, 2013, 439) (downgraded for risk of bias, inconsistency, indirectness, and imprecision). Significant heterogeneity (I-squared value 0.87) did not support pooling the data from these 3 studies.

Dallas 2015 Proposed Consensus on Science statements For the IMPORTANT outcome of 'survival to hospital discharge’: The Unadjusted Odds Ratios for survival to hospital discharge for children exposed to hypotension post ROSC: reported separately: Topjian; n=383; OHCA/IHCA: OR=0.62 [95% CI: ; p=0.022] Lin; n=152; non-traumatic OHCA: OR=0.10 [95% CI: ; p<0.001] Lin; n=80; traumatic OHCA: OR=0.08 [95% CI: ; p<0.001].

Dallas 2015 Proposed Consensus on Science statements For the IMPORTANT outcome of 'harm to patient' we have identified no evidence.

Dallas 2015 Draft Treatment Recommendations We suggest to avoid hypotension in children with ROSC after cardiac arrest (OHCA or IHCA) (weak recommendation, very low quality of evidence).

Dallas 2015 Knowledge Gaps The optimal strategy by which to avoid hypotension i.e. fluids versus inotropes and/or vasopressors is currently unclear The optimal perfusion endpoints to target (systolic blood pressure, mean blood pressure, measures of cardiac output, and/or other markers of perfusion eg. serum lactate) The optimal time period during which targeted measures of perfusion should be considered Harm to the patient or adverse effects as a result of use of parenteral fluids and inotropes and/or vasopressors to maintain targeted measures of perfusion? Subgroups of children who might respond differently to components of the intervention (eg. fluid response, changes in afterload, in cardiac patients/ trauma patients Parent/guardian satisfaction?

Dallas 2015 Next Steps This slide will be completed during Task Force Discussion (not EvRev) and should include: Consideration of interim statement Person responsible Due date