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Table of Contents
Year : 2020  |  Volume : 3  |  Issue : 4  |  Page : 356-361

Staying safe and saving precious lives: Pediatric life support during COVID-19 pandemic and beyond

Pediatric Intensive Care Unit, Department of Pediatrics, College of Medicine, King Saud University, Riyadh, Saudi Arabia

Date of Submission30-Jun-2020
Date of Decision08-Jul-2020
Date of Acceptance16-Jul-2020
Date of Web Publication02-Oct-2020

Correspondence Address:
Mohamad-Hani Temsah
Department of Pediatric, Pediatric Intensive Care Unit, College of Medicine, King Saud University, P O Box 14135, Riyadh 11424
Saudi Arabia
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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/JNSM.JNSM_79_20

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As COVID-19 was declared a pandemic by the World Health Organization in March 2020, the global community became on the alert toward optimizing patients' outcomes while maintaining the safety of health-care workers (HCWs). Providing cardiopulmonary resuscitation (CPR) to COVID-19 victims is further challenging, especially in the pediatric age group. This review describes the changes in the pediatric CPR guidelines after COVID-19, as well as potential resources to improve the patients' outcomes while maintaining HCWs' safety. We conducted a literature review on PubMed for all peer-reviewed publications on CPR in children with confirmed or suspected COVID-19. The search on June 25, 2020, retrieved the following results: “pediatric life support” AND COVID-19 (30 papers); CPR AND children AND COVID-19 (6 papers) CPR devise AND COVID-19 (11 papers). Twenty-four papers were retrieved after accounting for duplications. All the reviewed CPR guidelines in suspected or confirmed COVID-19 pediatric patients emphasize balancing the immediate needs of the victims with the priority of HCWs' own safety. Furthermore, in the pediatric age group, the rapid initiation of respiratory support is key to improving the outcome. We, therefore, recommend early recognition of the rapidly deteriorating child, such as through the Pediatric Rapid Response Team (PRRT), since such proactive measures could avoid risky CPR. This proactive PRRT would be much needed in the coming winter season, when more children may require critical care services. Implications of key findings: Early recognition of the rapidly deteriorating child to avoid or quickly prepare for possible CPR is advisable. Planning for the pediatric code teams before the next winter season is warranted.

Keywords: COVID-19, cardiopulmonary, pediatric

How to cite this article:
Temsah MH. Staying safe and saving precious lives: Pediatric life support during COVID-19 pandemic and beyond. J Nat Sci Med 2020;3:356-61

How to cite this URL:
Temsah MH. Staying safe and saving precious lives: Pediatric life support during COVID-19 pandemic and beyond. J Nat Sci Med [serial online] 2020 [cited 2023 Mar 23];3:356-61. Available from: https://www.jnsmonline.org/text.asp?2020/3/4/356/297121

  Introduction Top

As COVID-19 was declared a pandemic by the World Health Organization (WHO) in March 2020, the global community became on the alert toward optimizing patients' outcomes.[1] The pandemic spread rapidly, with 10 million documented cases as of June 26, and around half a million deaths worldwide.[2] There were major concerns about the significant risk of the highly transmissible disease among the health-care workers (HCWs), particularly during resuscitation, since the COVID-19 disease carries high morbidity and mortality rates.[3],[4] Hospital transmission of COVID-19 was the main cause of infection in HCWs.[5] Such infectious-disease outbreaks cause a substantial level of stress and anxiety among the HCWs who are providing medical care for infected patients, with their main concern from acquiring the disease themselves or the risk of transmitting the infection to their families.[6] There is extra emphasis on the prevention-and-control measures that each health-care facility should implement to avoid spreading the infection to other patients and to protect the HCWs.[7]

Relatively lesser cases of infants and children were confirmed to have COVID-19, and most have experienced mild illness.[8] Among 345 children with confirmed COVID-19, 23% were reported to have another underlying medical condition, such as asthma, cardiovascular disease, and immunosuppression.[9] As children with SARS-CoV-2 infection may develop acute cardiac decompensation, associated with a severe inflammatory reaction, following SARS-CoV-2 infection (recently labeled as multisystem inflammatory syndrome in children [MIS-C]), the life support procedures in this setting become more demanding.[10]

The HCWs were facing the unprecedented dilemma of balancing their personal safety with the immediate medical needs of their COVID-19 patients. This is even more challenging in the pediatric age group, where the rapid initiation of respiratory support is key to improving the outcome in these children. The American Heart Association (AHA) latest guidelines before the pandemic state that effective basic life support should be offered to infants and children as quickly as possible.[11] However, the advent of widespread viral disease outbreaks warranted updated guidelines and research that are being summarized in this review, keeping in mind that this novel disease is an emerging, rapidly evolving situation.

  Methods Top

Searches in PubMed and Cochrane Reviews were performed to identify articles published in English from the beginning of the COVID-19 pandemic to June 25, 2020. These databases were searched using keywords: “pediatric life support” AND COVID-19, and “cardiopulmonary resuscitation (CPR devise” AND COVID-19, CPR AND children AND COVID-19, PubMed search revealed (30 papers); “pediatric life support” AND COVID-19, (6 papers) for CPR AND children AND COVID-19, while for CPR devise AND COVID-19 (11 papers) were retrieved,. The same search on Cochrane Reviews matched 0 results on June 25, 2020.

The papers that were not related to pediatrics were excluded. Twenty-four papers were retrieved after accounting for duplications. A narrative review was synthesized using these included articles. We present the search results as a descriptive approach.

  Results Top

Main COVID-cardiopulmonary resuscitation guidelines' timeline

The pre-COVID resuscitation guidelines, such as the AHA pediatric CPR guidelines, did not specify the particular difficulties of performing CPR in the context of a pandemic, in which rescuers should balance their own safety with the immediate needs of the patients.[12] Therefore, soon after the WHO announced the pandemic, many interim guidelines and supplementary documents [Table 1] were published to address this gap and support the HCWs during the evolving crisis.
Table 1: COVID-cardiopulmonary resuscitation guidelines' timeline

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Noteworthy, these COVID-19 CPR guidelines do not apply to other patients who are proven to be COVID-19 negative, who should otherwise receive the prepandemic, standard life support. However, it is advisable to decrease the number of rescuers inside the patient's room for all CPR during the infectious disease outbreak to optimize social distancing.[12] Many of these recommendations were collaborative efforts of several societies to produce as comprehensive guidelines as feasible in such a rapidly evolving situation.[12],[13],[14]

While there were many updates in these organizations and societies' CPR recommendations during the COVID crisis, many CPR training centers had their activities suspended during the pandemic for fear of SARS-CoV-2 transmission between faculty and candidates during the CPR training courses and hands-on practices, with the AHA recommending not to have mass gatherings for such training.[14]

Focus on the health-care workers in the revised guidelines

As HCWs represent the highest risk profession for contracting the highly transmissible SARS-CoV-2, all the reviewed CPR guidelines in COVID-19-suspected or COVID-19-proven patients emphasized the need to prioritize the HCWs' safety. Several CPR measures are aerosol-generating procedures, such as chest compressions, positive pressure ventilation, and airway intubation. The viral particles can remain airborne in the CPR scene, with a half-life of one hour.[23] A recent systemic review revealed that there is still uncertainty whether chest compressions or defibrillation during resuscitation is aerosol generating with transmission risk to rescuers.[24]

There is evidence suggesting that during a 2-min period, neither the chest compression quality on a child manikin nor the HCWs fatiguability worsened in providers wearing personal protective equipment (PPE).[25] Furthermore, resuscitation efforts involve many HCWs working near one another and the victim, predisposing. Any lapses in infection control measures during such emergencies could expose several HCWs to unwarranted infectious risks.[25]

Furthermore, resuscitation efforts involve many HCWs working near one another and the victim, predisposing. Any lapses in infection control measures during such emergencies could expose several HCWs to unwarranted infectious risks.

Prearrest changes

The new guidelines recommend closely monitoring for early changes in the signs and symptoms for earlier detection of clinical deterioration, along with proactive interventions, as this may decrease the need for emergent airway intubations or CPR, which may predispose the patients and HCWs to more risk. It is also advised to move such high-risk patients to a negative pressure room, to lessen the risk of infectious exposure to rescuers during a resuscitation, keeping the doors closed to minimize airborne contamination of other clinical areas.[12]

Cardiopulmonary resuscitation changes

One of the main rules for CPR in suspected or confirmed COVID-19 patients is protecting HCWs from unnecessary exposure to SARS-CoV-2. Therefore, before entering the CPR scene, HCWs should be alerted that the victim is COVID-19 suspected, and all the team must don proper PPE. Several studies demonstrated the importance of PPE in protecting HCWs from aerosols during CPR.

The HCWs inside the room or at the CPR scene must be limited to the essential personnel for resuscitation. The AHA guidelines recommend replacing the manual chest compressions with mechanical CPR compression devices to decrease the number of HCWs required for adolescent victims who meet the manufacturer's weight and height standards.

Another recommendation to minimize HCWs risk is by achieving oxygenation and ventilation approaches with lesser aerosolization risk. The new guidelines emphasize the use of viral or high-efficiency particulate air (HEPA) filter to any manual or mechanical ventilation device in the pathway of the exhaled gas before administering any breaths. Furthermore, the team is encouraged for early intubation with a cuffed endotracheal tube, and to connect to a ventilator with heat and moisture exchanger (HME) filter (HEPA grade) in the exhaled gas tubes, as well as adding an in-line suction catheter. This closed respiratory circuit has a lesser risk of aerosolization than other forms of positive pressure ventilation.[26]

During the endotracheal intubation process, the new guidelines recommend minimizing the probability of failed intubation attempts by assigning the airway intubation to the most experienced provider with the best chance of first-pass intubation success. Furthermore, the chest compressions should be paused to intubate, to facilitate the process, while in the non-COVID CPR, the priority was to optimize chest compressions with minimal interruptions.

If the patient was already intubated before cardiac arrest, the recent guidelines advocate keeping the victim on the mechanical ventilator to maintain the closed circuit and reduce aerosolization, with maximization of the ventilator's settings during the CPR.[12]

Additional measures

Extra barriers during aerosolization procedures

Heat and moisture exchanger filter

there is an emphasis in the updated guidelines to incorporate a viral filter or HME filter that is HEPA quality with any ventilator circuit for COVID-suspected patients, whether it is in use with bag-and-mask ventilation or in the ventilator expiratory circuit[12],[27] [Figure 1]a.
Figure 1: (a) Heat and moisture filter (HEPA grade). (b) Intubation box

Click here to view

Video laryngoscope

Video laryngoscopy was added to the guidelines, if available, as this practice may reduce intubator exposure to aerosolized particles. While such a video laryngoscopy tool may not be available for many HCWs, still, some described modifying the conventional laryngoscope into a 150$ video-laryngoscope set.[28]

The intubation box

Some medical professionals advocated the intubation box, which is intended to provide an additional barrier between the intubator and the COVID-suspected patient during the intubation process [Figure 1]b. However, there is no standardization of this intubation box in the literature and no peer-reviewed research to its added benefit or harm in the real CPR setting. While some experts proposed that this additional barrier method was user-friendly and can be a valuable and economical option to protect HCWs on the frontline,[29],[30] other research done in a simulated setting showed the added disadvantage of increased intubation times and potential damage to conventional PPE and therefore places HCWs at risk of infection.[31] Caution is needed at this time, as more evidence is needed about the benefits or drawbacks of using these intubation boxes in the pediatric setting.

Prone compressions

The recent guidelines specify more details about CPR in patients in the prone position at the time of arrest, as this modality is used frequently in COVID patients. Although the efficiency of CPR in this position is not yet established, for those patients who are already proned with an advanced airway, it is recommended to keep them proned if there is a risk of equipment disconnections and aerosolization. Instead, the rescuer can provide CPR with the patient remaining proned with hands in over the T7/10 vertebral bodies, placing the defibrillator pads in the anterior-posterior position.[32]

After cardiopulmonary resuscitation

The recent guidelines emphasize applying the local hospital infection control recommendations regarding the transport of COVID-19 patients after resuscitation.[12] Moreover, to reduce the risk of SARS-COV2 transmission, many experts advised extra caution when using the stethoscope in these settings. HCWs should clean the stethoscope's plastic diaphragm at the same time as disinfecting their hands.[33] Furthermore, stethoscopes that are used by several HCWs should be avoided whenever possible, to prevent potential self-inoculation or nosocomial spread.[33] Some experts suggest utilizing other alternative methods to reduce the X-ray needs in COVID-19 patients, such as lung point-of-care ultrasound, as it is still an underutilized valuable alternative, especially when using pocket devices.[34]

Practice makes perfect

In several settings, valuable lessons were learned from simulation on individual and system levels, with a simulation drill with infection control colleagues along.[35] Several schematic representations[3] were published to suggest the CPR team who is present inside the negative pressure room (the hot zone) versus the support HCWs in the ante-room who offer help to the CPR team as needed (the warm zone), while the HCWs who are not related to the CPR remain in the safe cold-zone, to minimize the exposure risk. In those situations, a nurse will stay in the anteroom and make sure that no one other than the assigned CPR team members will be inside the room.

Communication and personal protective equipment

Proper communication between the rescuers is a key element in proper CPR. However, the communication process may be more challenging in COVID-19 settings, where all the HCWs must wear their full PPE, which includes masks and face shields. A simulated study that demonstrated the loose-fitting powered air-purifying respirators (PAPRs) during resuscitation provided enough respiratory protection during chest compression, however, 24% reported having difficulty in listening when wearing the PAPRs.[36]

Psychological support for health-care workers pre, during, and after a code

HCWs on the frontlines have described the psychological distress during the pandemic as “probably 100 times what they could have imagined it was in the past,” with much of this stress due to the uncertainty about the rapidly evolving COVID-19.[37] CPR in a COVID-19 suspected or confirmed child is a high-stress emergent event, in which the immediate needs of the child and the caregiver may cause gaps in infection control practices.[12] The literature recognized six possible occupational risk categories to HCWs in the resuscitation team, namely infectious, electrical, musculoskeletal, chemical, irradiative, and psychological.[38] Therefore, psychological support for any CPR team is warranted, especially during the current pandemic crisis, where such risk factors may co-exist. Further research on the specific psychological risks and support needs for the COVID-19 CPR teams will be one of the areas to explore in the future.

Patients and family involvement

For children, the revised guidelines advocate that the lay rescuers should perform chest compressions and if they are from the same household, also to consider mouth-to-mouth ventilation, especially with the higher incidence of respiratory arrest in infants and children.[12] It is also recommended that parents and caregivers of children with suspected or confirmed COVID-19 should not ride in the same ambulance, to minimize the risk of transmission.

Ethical considerations

For children with poor long-term prognosis, earlier discussion among the treating teams and the parents about the code status is warranted, as part of a holistic management approach, as well as to reduce the probability of unnecessary CPR in such infectious disease outbreaks.[12],[39] While all HCWs strive to the best possible care, the challenge is to ensure that pediatric victims, with or without COVID-19 who experience cardiorespiratory arrest, receive the best possible survival while maintaining the safety of rescuers throughout the process. The HCWs are essential for the continued medical care for future patients,[12] so optimizing their safety is ethically and practically warranted during the outbreak. Exposed HCWs who develop COVID-19 would further diminish the already stressed health-care workforce, with the potential to add extra burden if they become severely ill themselves.

Considering the usefulness of resuscitation efforts in COVID-19 patients, the new guidelines emphasize that CPR is a high-intensity procedure that requires significant resources and may divert the HCWs' attention from other patients.[40] Furthermore, in the setting of COVID-19, the risk to the HCWs is much augmented, and the medical resources can be severely affected, especially in areas that are suffering a high number of patients. Therefore, it is advised to consider other comorbidities and severity of illness in the clinical judgment about the appropriateness of resuscitation and balance the likelihood of successful outcomes against the risk to HCWs and other patients from whom resources are being diverted.[41]

Preparation for the winter season

Many pediatric illnesses are encountered more frequently in the winter months, such as respiratory tract infections (peak in January), gastroenteritis (peak in February–March), and asthma (peak in March and October).[42] As the seasonal variation in pediatric hospitalization is expected, therefore, prompt preparedness of the PRRT and pediatric intensive care units (PICUs) should parallel these, especially with the yet unexpected COVID-19 status during the next winter season. The utilization of PRRT was shown to reduce PICU-admission illness severity, length of stay, and mortality.[43] PRRT implementation led to earlier capture and aggressive intervention for the decompensating pediatric ward patient, potentially avoiding further clinical deterioration and CPR needs. Future integration of PRRT activation in the patient's medical monitoring could automate this process. The pediatric early warning scores (PEWS) is frequently used for early identification of hospitalized children at risk for clinical deterioration. To empower this PEWS more, one recent study compared it with electronic health records automated calculations (AutoPEWS). The AutoPEWS was found to be more accurate, and this could help the HCWs during current or future healthcare crisis, allowing automated and faster detection of possible clinical deterioration.[44]

  Conclusion Top

CPR in COVID-19-suspected or COVID-19-confirmed children needs to follow the latest resuscitation guidelines, prioritizing the safety of HCWs during such emergencies, where rapid initiation of respiratory support is key to improving the children's outcome. Furthermore, pediatric teams should be ready to cope with an increased number of respiratory and MIS-C emergencies during the winter season. We recommend early recognition of the rapidly deteriorating child, such as through the PRRT, as the proactive measures could avoid risky CPR.

Financial support and sponsorship


Conflicts of interest

There are no conflicts of interest.

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