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Post-ROSC Fluid/Inotropes

Question Type:
Intervention
Full Question:
In infants and children after ROSC

  (P), does the use of parenteral fluids and inotropes and/or vasopressors to maintain targeted measures of perfusion such as blood pressure (I), compared with  not using these interventions (C), change  (O)?
Consensus on Science:
For the critical outcome of survival to hospital discharge with good neurologic outcome, we identified very-low-quality evidence from 1 pediatric observational study of IHCA and OHCA (downgraded for risk of bias, indirectness, and imprecision(Topjian 2014, 1518-1523)) involving 367 children, showing worse outcomes when subjects experienced blood pressures less than fifth percentile for age after ROSC (RR, 0.78; 95% CI, 0.62–0.99). For the important outcome of survival to hospital discharge, we identified very-low-quality evidence from 3 pediatric observational studies of IHCA and OHCA (downgraded for risk of bias, inconsistency, indirectness, and imprecision(Lin 2010, 410-417; Lin 2013, 439-447; Topjian 2014, 1518-1523)) involving a total of 615 subjects, showing worse outcomes when children experienced hypotension after ROSC. Significant heterogeneity (I-squared value 0.87) did not support pooling the data from these 3 studies (Topjian: OR, 0.62; CI, 0.41–0.93; Lin, 2010: OR, 0.10; CI, 0.03–0.32; and Lin, 2013: OR, 0.08; CI, 0.02–0.03).For the important outcome of harm to patient, we identified no evidence.
Treatment Recommendation:
We recommend that for infants and children after ROSC, parenteral fluids and/or inotropes or vasopressors should be used to maintain a systolic blood pressure of at least greater than the fifth percentile for age (strong recommendation, very-low-quality evidence).Values, Preferences, and Task Force Insights In making this recommendation, we place a higher value on avoiding mortality and progressive organ failures from the effects of hypotension than on unknown harms that may be associated with the use of fluids, inotropes, or vasopressors. Although the measurement of blood pressure has limitations in determining perfusion of vital organ, it is a practical and valued measurement of hemodynamic status. The task force made a strong recommendation despite the weakness of the available evidence, owing to the intuitive need to avoid hypotension where there is a likely association with reduced perfusion of vital organs.
CoSTR Attachments:
GRADE Should the use of parenteral fluids and inotropes andor vasopressors [FINAL].pdf    
Peds 820 Bias assessment.png    
Peds820_recommendations.pdf    
Peds820_references_n.docx    

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