Update in Paediatric Advanced Life Support
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Fran Lockie, a Paediatric Emergency and retrieval specialist, gives an update on paediatric resuscitation. This talk was given at the Bedside Critical Care Conference 2012 on Daydream Island.
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Update in Paediatric Advanced Life Support
- 1. Paediatric Resuscitation Update Bedside Critical Care, Daydream Island September 2012 Dr Francis Lockie, Paediatric Emergency Department Women’s and Children’s Hospital MedSTAR Emergency Medical Retrieval South Australia
- 2. Talk outline • Scope of arrests in children – Out-of hospital – In hospital • Resus update • Improve survival – Training – Met teams
- 3. Out-of-Hospital Pediatric Cardiac Arrest: An Epidemiologic Review and Assessment of Current Knowledge Ann Emerg Med. 2005 Dec;46(6):512-22 41 studies 5000 out of hospital paediatric arrests Overall survival 12.1%, Neurologically intact 4%
- 4. JAMA. 2006;295(1):50-57 Survival to hospital discharge 27% in kids (vs 18% in adults) Good neurological outcome in 17% (vs 13%) OR First pulseless rhythm oVF/pulseless VT: 14% vs 23% oAsystole 40% vs 35% oPEA 24% vs 32%
- 5. • Arrest in 111 of >100 000 admissions • ROSC in 73% • Survival to discharge 36% • Hypotensive-bradycardia 66% • Asystole 15% • VF / pulseless VT 9% • SVT
- 6. 2010 Update
- 11. JAMA. 2010;304(13):1447-1454 No bystander CPR 5.2% Conventional CPR 7.8% COCPR 13.3% JAMA. 2010;304(13):1447-1454
- 13. Uncuffed Cuffed – Age/4 + 4 – Age/4 + 3 – Minimize airway – Improved airway oedema protection – Larger internal – Higher airway diameter pressures – Age/2+12 cm at – Reduced lips (oral) laryngoscopy attempts Pediatric Anesthesia 2009 19 (Suppl. 1): 46–54
- 16. Where exactly does the intraosseous (IO) fit? ILCOR 2005 ILCOR 2010
- 17. Where exactly does the intraosseous (IO) fit? Concerns re: complications •Pain •Success •Extravasation •Growth plate injury •osteomyelitis
- 18. • 95 patients • Mean age 5.5 • 95% success • 10 seconds or less • Pain score 2.3 Pediatr Emerg Care 2008
- 19. Hansen Pediatr Emerg Care 2011 • 291 patients • 34% arrested • 86% placed in community hospitals • 37% mortality • NO COMPLICATIONS
- 22. Pediatr Crit Care Med 2009 Vol. 10, No. 3 • Total hospital deaths decreased from 4.38 to 2.87 / 1000 admissions • 34 hospital deaths prevented each year of MET operation • Survival increased from 35% to 74% • Annual calls went from 46 to 202 with MET
- 23. 3 days 1 day 90mins 1920-2120 350-500 Free
- 24. • The first 5 -10 minutes of aRescuers Paediatric Life Support for Healthcare paediatric collapse in a healthcare setting Basic Life Support occurs in the community by lay • Includes CRM: equipment people with no or little teamwork, leadership • Good uptake – 8000 completed the e-learning – 3600 completed short practical course – 517 trainers – 30 Super trainers
- 25. • Will be pre-requisite for DETECT junior in NSW • Adopted by Sunshine Coast, Qld • Adopted by ACT Health • Available to other States and Territories for minimal cost Resus4kids.com.au fenton.oleary@health.nsw.gov.au
- 26. Other issues covered • Family presence during resus • ECMO • Complex congenital heart disease • Trauma – C-A-B approach – Fluid restrictive resus
- 27. Other issues covered • Family presence during resus • ECMO • Complex congenital heart disease • Trauma – C-A-B approach – Fluid restrictive resus • Don’t forget – Parent education – Public health measures
- 28. Summary • Scope of paediatric arrests • Whip through some recent changes • How we can improve paediatric resus outcomes for our patients – Individual – Hospitals – State
Notas del editor
- There’s a big difference between out of hospital and in hospital arrests It’s interesting to see that there has been virtually no improvement in survival for pre-hospital arrest in the 50years since CPR has been developed. Incidence has gone down: that’s all down to public health! It’s a different story if you arrest in hospital! There’s been a huge improvement in survival if you arrest in hospital. Thanks to improvement sin resuscitation and training on many different levels. Look at some of the updates recommended by 2010 ILCOR collaborative and how they have been interpreted locally and internationally I’m going to talk about how we can improve the survival from paediatric cardiac arrest Let’s upskill ouselves but we have a responsibility to train others Can we improve things by training? Who should we train, and how What about Simulation What systems do we need to have in place to detect critical illness early How can we train junior doctors, medical students, nurses and ancillary staff to be expert resuscitators
- 41 studies >5000 12.1 and 4% intact Cf 5-13 % in adults reported in the 2010 JAMA article comparing no CPR - COCPR Submersion better22.7 /6 Better outcome with bystander CPR (OR 1.99 1.54-2.57)
- BETTER SURVIVAL IN KIDS AND BETTER NEUROLOGICAL OUTCOME I WAS SURPRISED BY THE NUMBER OF KIDS PRESENTING WITH A SHOCKABLE RHYTHM SO WE REALLY HAVE TO KNOW OUR ALGORITHMS BACKWARDS NOT SURPRISINGLY MORE KIDS HAVE PEA ASYSTOLE NOT ALL BAD NEWS: IF KIDS HAVE PEA ? ASYSTOLE THEY ARE MORE LIKELY TO SURVIVE THAN THEIR ADULT COUNTERPARTS THIS SAYS KIDS MORE RESILIENT THAN ADULTS AFER PEA ? ASYSTOLE Context Cardiac arrests in adults are often due to ventricular fibrillation (VF) or pulseless ventricular tachycardia (VT), which are associated with better outcomes than asystole or pulseless electrical activity (PEA). Cardiac arrests in children are typically asystole or PEA. Objective To test the hypothesis that children have relatively fewer in-hospital cardiac arrests associated with VF or pulseless VT compared with adults and, therefore, worse survival outcomes. Design, Setting, and Patients A prospective observational study from a multicenter registry (National Registry of Cardiopulmonary Resuscitation) of cardiac arrests in 253 US and Canadian hospitals between January 1, 2000, and March 30, 2004 . A total of 36 902 adults (≥18 years) and 880 children (<18 years) with pulseless cardiac arrests requiring chest compressions, defibrillation, or both were assessed. Cardiac arrests occurring in the delivery department, neonatal intensive care unit, and in the out-of-hospital setting were excluded. Main Outcome Measure Survival to hospital discharge. Results The rate of survival to hospital discharge following pulseless cardiac arrest was higher in children than adults (27% [236/ 880 ] vs 18% [6485/ 36 902 ]; adjusted odds ratio [OR], 2.29; 95% confidence interval [CI], 1.95-2.68). Of these survivors, 65% (154/236) of children and 73% (4737/6485) of adults had good neurological outcome. The prevalence of VF or pulseless VT as the first documented pulseless rhythm was 14% (120/880) in children and 23% (8361/36 902) in adults (OR, 0.54; 95% CI, 0.44-0.65; P <.001). The prevalence of asystole was 40% (350) in children and 35% (13 024) in adults (OR, 1.20; 95% CI, 1.10-1.40; P = .006), whereas the prevalence of PEA was 24% (213) in children and 32% (11 963) in adults (OR, 0.67; 95% CI, 0.57-0.78; P <.001). After adjustment for differences in preexisting conditions, interventions in place at time of arrest, witnessed and/or monitored status, time to defibrillation of VF or pulseless VT, intensive care unit location of arrest, and duration of cardiopulmonary resuscitation, only first documented pulseless arrest rhythm remained significantly associated with differential survival to discharge (24% [135/563] in children vs 11% [2719/24 987] in adults with asystole and PEA; adjusted OR, 2.73; 95% CI, 2.23-3.32). Conclusions In this multicenter registry of in-hospital cardiac arrest, the first documented pulseless arrest rhythm was typically asystole or PEA in both children and adults. Because of better survival after asystole and PEA, children had better outcomes than adults despite fewer cardiac arrests due to VF or pulseless VT.
- HOW ABOUT IN AUSTRALIA? STUDY FROM RCH MELBOURNE REPORT 111 arrests in >100 000 ADMISSIONS SEEM TO BE DOING BETTER THAN THE REST OF THE WORLD!ACTUALLY Majority occurred in CICU Also reported on respiratory arrests from which survival was 97% BACKGROUND: Few prospective studies of the incidence and outcome of paediatric in-hospital cardiopulmonary arrest have been reported to enable quality assurance comparisons within and between institutions. METHODS: All cardiac and respiratory arrests and their management over a 41-month period in children not subject to palliative treatment or to a 'do not resuscitate' order were recorded and analysed using the Utstein template. RESULTS: Cardiac arrest occurred in a total of 111 of 104,780 admissions (1.06/1000) while respiratory arrest alone occurred in 36 (0.34/1000). Return of spontaneous circulation (ROSC) was achieved in 81 patients (73%) in cardiac arrest but only 40 (36%) were discharged from hospital and 38 (34%) survived for 1 year. The 1-year survival from respiratory arrest alone was 97%. Cardiac arrest was four times more common (89 versus 22) and approximately 90 times the incidence in the intensive care unit compared with wards but 1-year survival was similar (34% versus 36%). The initial heart rhythms were hypotensive-bradycardia in 73 (66%) with 38% survival; asystole in 17 (15%) with 12% survival; ventricular fibrillation (VF) or pulseless ventricular tachycardia (VT) in 10 (9%) with 40% survival; pulseless electrical activity (PEA) in 10 (9%) with 30% survival and SVT in 1 with survival. Secondary ventricular fibrillation occurred in 15 children given adrenaline (epinephrine) for treatment of asystole, hypotensive-bradycardia or PEA of whom 11 had received adrenaline in an initial dose of > 15 mcg/kg and 4 had < 15 mcg/kg (P = 0.0013). Eleven of 15 patients (73%) in secondary VF never achieved ROSC. CONCLUSIONS: In-patient paediatric cardiac arrest has a mediocre outcome with a better outlook if the initial rhythm is hypotensive-bradycardia, VF or pulsatile VT. Doses of adrenaline greater than 15 mcg/kg given for non-shockable rhythms may cause secondary VF which has a worse outcome than primary VF.
- NOW LET’S MOVE ON TO RESUS UPDATES ILCOR and CoSTR (Consensus on science with treatment recommendations) October 2010 277 resus topics reviewed over 36 months 356 experts from 29 countries Forms guidelines for many resus councils including ARC NZRC AHA: differs significantly from
- I’t clear that there are different interpretations of the ILCOR CONSENCUS ON SCIENCE WITH TREATMENT RECOMMENDATIONS and It’s still an elephant, just looking it from different viewpoints.
- DRSABC APPROACH COMMON TO ADULTS AND KIDS Two initial breaths rather than 5 breaths to achieve 2 effective breaths Recognises that kids more likely to have hypoxic aetiology for their arrest than adult counterparts. Central pulse for 10 seconds OR SIGNS OF LIFE EVEN THIS HAS BEEN CONTROVERSIAL IN AUSTRALIAN PAEDS COMMUNITY AND CHANGING COURSE CONTENT HAS BEEN A STRUGGLE A TIMES.
- INTERPRETATION initially appearsVERY DIFFERENT IN THE US ACTUALLY SIMILAR RECOGNISES THAT ACTIONS OCURR SIMULTANEOUSLY IN THE TIME IT TAKES FOR SOMEONE TO GET OXYGEN , BVM, COMPRESSIONS COULD HAVE STARTED THE EUROPEANS HAVE STAYED WITH THE A-B-C approach and still advocate 5 rescue breaths Context Chest compression–only bystander cardiopulmonary resuscitation (CPR) may be as effective as conventionalCPRwith rescue breathing for out-of-hospital cardiac arrest. Objective To investigate the survival of patients with out-of-hospital cardiac arrest using compression-only CPR (COCPR) compared with conventional CPR. Design, Setting, and Patients A 5-year prospective observational cohort study of survival in patients at least 18 years old with out-of-hospital cardiac arrest between January 1, in , 2005, and December 31, 2009 Arizona . The relationship between layperson bystander CPR and survival to hospital discharge was evaluated using multivariable logistic regression. Main Outcome Measure Survival to hospital discharge. Results Among 5272 adults with out-of-hospital cardiac arrest of cardiac etiology not observed by responding emergency medical personnel, 779 were excluded because bystander CPR was provided by a health care professional or the arrest occurred in a medical facility. A total of 4415 met all inclusion criteria for analysis, including 2900 who received no bystander CPR, 666 who received conventional CPR, and 849 who received COCPR. Rates of survival to hospital discharge were 5.2% (95% confidence interval [CI], 4.4%-6.0%) for the no bystander CPR group, 7.8% (95% CI, 5.8%-9.8%) for conventional CPR, and 13.3% (95% CI, 11.0%-15.6%) for COCPR. The adjusted odds ratio (AOR) for survival for conventional CPR vs no CPR was 0.99 (95% CI, 0.69-1.43), for COCPR vs no CPR, 1.59 (95% CI, 1.18-2.13), and for COCPR vs conventional CPR, 1.60 (95% CI, 1.08-2.35). From 2005 to 2009, lay rescuer CPR increased from 28.2% (95% CI, 24.6%-31.8%) to 39.9% (95% CI, 36.8%-42.9%; P .001); the proportion of CPR that was COCPR increased from 19.6% (95% CI, 13.6%-25.7%) to 75.9% (95% CI, 71.7%-80.1%; P .001). Overall survival increased from 3.7% (95% CI, 2.2%-5.2%) to 9.8% (95% CI, 8.0%-11.6%; P .001). Conclusion Among patients with out-of-hospital cardiac arrest, layperson compression-only CPR was associated with increased survival compared with conventional CPR and no bystander CPR in this setting with public endorsement of chest compression–only CPR. JAMA. 2010;304(13):1447-1454 www
- This could be the most important slide you see at this entire conference! Certainly having done my first APLS course about 10 years ago the following day I was faced with a blue, conscious child with an ineffective cough. Small piece of a plastic wrapper went flying across the room and normal play was resumed!
- Concensus is emerging in the paediatric anaesthetic and ICU communities and it is common practice for cuffed ETT to be used in children over 1. In the era of safer high volume / low pressure ET cuffs mucosal ischaemia is rare if cuff inflating pressure is monitored and limited according to manufacturer’s instruction (usually less than 20 to 25 cm H2O). In theatre, cuffed endotracheal tubes are associated with a higher likelihood of correct selection of tube size, thus achieving a lower reintubation rate with no increased risk of perioperative complications. In intensive care settings the risk of complications in infants and in children is no greaterwith cuffed tubes than with noncuffed tubes. Cuffed endotracheal tubes may decrease the risk of aspiration. If cuffed endotracheal tubes are used, In certain circumstances (eg, poor lung compliance, high airway resistance, or a large glottic air leak) a cuffed endotracheal tube may be preferable to an uncuffed tube,provided that attention is paid to endotracheal tube size, position, and cuff inflation pressure
- It’s amazing what can be achieved with good effective ventilation! bag-mask ventilation remains the recommended first line method for achieving airway control and ventilation in children, the LMA is an acceptable airway device for providers trained in its use.81,82 It is particularly helpful in airway obstruction caused by supraglottic airway abnormalities or if bag-mask ventilation is not possible. The LMA does not totally protect the airway from aspiration of secretions, blood or stomach contents, and therefore close observation is required. Use of the LMA is associated with a higher incidence of complications in small children compared with adults. The safety and value of using cricoid pressure during tracheal intubation is not clear. Therefore, the application of cricoid pressure should be modified or discontinued if it impedes ventilation or the speed or ease of intubation.
- GOOD NEWS HERE< IT”S ALMOST IDENTICAL TO ADULT ALGORITHM Emphasis here on high quality CPR, minimising interruptions Vigorous attention to detail Early recognition of shockable rhythm, maintaining CPR until the defib is charged Early recognition of reversible causes
- 2005 ILCOR recommendation for IO use in cardiac arrest clear and widely accepted Increasing availability of drill powered insertion device (EZI IO) 2010 ILCOR reiterated message but added “ ..IO should be considered early in the care of critically ill children whenever venous access is not readily available ” 2010 multi-organisation consensus statement “ ….for whom vasc access cannot be readily or safely obtained IO access may prove a safe and viable alternative…. ”
- 2005 ILCOR recommendation for IO use in cardiac arrest clear and widely accepted Increasing availability of drill powered insertion device (EZI IO) 2010 ILCOR reiterated message but added “ ..IO should be considered early in the care of critically ill children whenever venous access is not readily available ” 2010 multi-organisation consensus statement “ ….for whom vasc access cannot be readily or safely obtained IO access may prove a safe and viable alternative…. ”
- Objective: For decades, intraosseous (IO) access has been a standard of care for pediatric emergencies in the absence of conventional intravenous access. After the recent introduction of a battery-powered IO insertion device (EZ-IO; Vidacare Corporation, San Antonio, TX), it was recognized that a clinical study was needed to demonstrate device safety and effectiveness for pediatric patients. Methods: We measured the insertion success rate, patient pain levels during insertion and infusion, insertion time, types of fluid and drugs administered, device ease of use on a scale of 1 (easy) to 5 (difficult), and complications. Results: There were 95 eligible patients in the study; 56% were males. Mean patient age was 5.5 ± 6.1 years. Successful insertion and infusion was achieved in 94% of the patients. Insertion time was 10 seconds or less in 77% of the one-attempt successful cases reporting time to insertion. There were 4 minor complications (4%), but none significant. For patients with a Glasgow Coma Scale (GCS) score >8, mean insertion pain score was 2.3 ± 2.8, and mean infusion pain score was 3.2 ± 3.5. The device was rated easy to use 71% of the time (n = 49) and the mean score was 1.4. Conclusions: The results of this study support the use of the powered IO insertion device for fluid and drug delivery to children in emergency situations. The rare and minor complications suggest that the powered IO device is a safe and effective means of achieving vascular access in the resuscitation and stabilization of pediatric patients.
- 2005-2007, 291 patients across 90 hospitals (4/10 5 ED visits) Range of primary diagnoses, 34% were in cardiac arrest….others 86% of IOs placed in “ community hospital 37% mortality No complications related to IO line noted
- Many AEDs can accurately detect VF in children of all ages.They can differentiate “ shockable ” from “ nonshockable ” rhythms with a high degree of sensitivity and Specificity It is recommended that systems and institutions that have AED programs and that care for children should use AEDs with a high specificity to recognize pediatric shockable rhythms and a pediatric attenuating system that can be used for infants and children up to approximately 25 kg (approximately 8 years of age)If an AED with an attenuator is not available, use an AED with standard electrodes (Class IIa, LOE C). In infants 1 year of age a manual defibrillator is preferred. If a manual defibrillator is not available, an AED with a dose attenuator may be used. An AED without a dose attenuator may be used if neither a manual defibrillator nor one with a dose attenuator is available (Class IIb, LOE C).
- Let’s not forget the neonates! There is no more delay thinking which algorithm am I going to use! Strictly in the delivery room only They should now be resuscitated in air and oxygen only used if they are persistently bradycardic
- PREVENTION BETTER THAN CURE and there are many early warning systems in place throughout the country Medical Emergency Team (MET – lead clinician Dr James Tibballs, Melbourne) – Children’s Early Warning Tool (CEWT) Kevin McCaffery – Paediatric Compass (lead clinician Dr Tony Lafferty, Canberra) – Paediatric Between The Flags (lead clinician Dr Jonny Taisz, Objective: To determine the effect of a medical emergency team (MET) on the incidence of unexpected cardiac arrest and death. Design: Comparison of retrospective data (pre-MET) before introduction of MET with prospective data after introduction of MET system (post-MET). Setting: Tertiary care pediatric hospital. Patients: A total of 104,780 admissions during a 41-month period pre-MET; 138,424 admissions during 48 months post-MET. Interventions: Introduction of a MET. Results: Total hospital deaths decreased from 4.38 to 2.87/ 1000 admissions (risk ratio 0.65, 95% confidence interval CI 0.57– 0.75, p < 0.0001). Ward unexpected death decreased from 13 (0.12/1000) to 6 (0.04/1000) (risk ratio 0.35, 95% CI 0.13– 0.92, p 0.03) but unexpected cardiac arrests did not change from 0.19/1000 to 0.17/1000 (risk ratio 0.91, 95% CI 0.50 –1.64, p 0.75). Thirty-four hospital deaths, including three unexpected deaths (1 out of 72 MET calls), were prevented each year of MET operation. Preventable cardiac arrest (children whose symptoms or signs fulfilled MET calling criteria) decreased from 17 (0.16/ 1000) to 10 (0.07/1000) (risk ratio 0.45, 95% CI 0.20–0.97, p 0.04) and in whom death decreased from 12 to 2 (0.11/1000 to 0.01/1000) (risk ratio 0.13, 95% CI 0.03– 0.56, p 0.001). Nonpreventable cardiac arrest (children whose symptoms or signs did not fulfill MET calling criteria) increased from 3 to 14 (0.03/1000 to 0.10/1000, p 0.03) but death did not increase. Survival from cardiac arrest increased from 7 of 20 patients to 17 of 23 (risk ratio 2.11, 95% CI 1.11– 4.02, p 0.01). Annual calls for urgent assistance were 202 in the post-MET era and 46 during the pre-MET era (ratio 4.4:1). Conclusions: Introduction of a MET was associated with reduction of total hospital death and reduction of preventable cardiac arrest and death with increased survival in wards of a pediatric hospital. MET calling criteria identified some but not all children at risk of unexpected cardiac arrest and death. (Pediatr Crit Care Med 2009; 10:306 –312) KEY WORDS: medical emergency team; cardiac arrest; death;
- Enhancing Urgent Paediatric Care in NSW The Minister for Health, Jillian Skinner, today launched a range of clinical resources aimed at enhancing the recognition and management of sick infants and children in urgent or deteriorating situations. The resources were announced at the Child Health Networks Forum, “Caring for Children – Wherever they are.” The initiative is part of a state-wide education and support program. Mrs Skinner said the forum highlighted collaboration and mutual support across the spectrum of healthcare for children, with particular emphasis on rural facilities and acutely sick patients. “ Our clinicians in emergency departments and children’s wards are at the frontline of urgent action, and in effect are the ‘lifeguards’ of our hospitals,” Mrs Skinner said. “ These tools will further enhance the skills and knowledge for our clinical staff in handling patients who present as an emergency or with deteriorating conditions,” she said. “ Our priority is to equip our frontline staff with quality resources to allow them to continue providing patients with the safest possible care.” The new clinical resources are: The first chapter of the DETECT Junior manual: an online paediatric education program developed to enhance the recognition and management of clinically deteriorating infants and children. The NSW Rural Paediatric Emergency Clinical Guidelines : a companion document to help outline procedures to ensure the early management of children who present to Emergency Departments where Medical Officers are not immediately available. The Recognition of the Sick Baby or Child in the Emergency Department : guidelines to assist clinicians in early and rapid recognition of imminent risk in our young and very vulnerable patients. The resources have been developed through a collaboration of the Clinical Excellence Commission, the Rural Critical Care Taskforce and the Child Health Networks in NSW. All three resources help ensure that children who need it most receive safe and appropriate care wherever they are in NSW.
- Family Presence During Resuscitation Family presence during CPR is increasingly common, and most parents would like to be given the opportunity to be present during resuscitation of their child.462–471 Studies show that family members who are present at a resuscitation would recommend it to others.462,463,465,471,472 Parents of chronically ill children are comfortable with medical equipment and emergency procedures, but even family members with no medical background who were at the side of a loved one to say goodbye during the final moments of life believe that their presence was beneficial to the patient,462–464,466,471–476 comforting for them,462–465,468–471,476 and helpful in their adjustment463–465,472,473,476,477 and grieving process.477 Standardized psychological examinations suggest that, compared with those not present, family members present during attempted resuscitations have less anxiety and depression and more constructive grieving behavior.477 Parents or family members often fail to ask, but healthcare providers should offer the opportunity in most situations.474,478,479 Whenever possible, provide family members with the option of being present during resuscitation of an infant or child (Class I, LOE B).474,478,479 Family presence during resuscitation, in general, is not disruptive, 464,472,475,476,480,481 and does not create stress among staff or negatively affect their performance.462,464,480,482 If the presence of family members creates undue staff stress or is considered detrimental to the resuscitation,483 then family members should be respectfully asked to leave (Class IIa, LOE C). Members of the resuscitation team must be sensitive to the presence of family members, and one person should be assigned to remain with the family to comfort, answer questions, and
- Family Presence During Resuscitation Family presence during CPR is increasingly common, and most parents would like to be given the opportunity to be present during resuscitation of their child.462–471 Studies show that family members who are present at a resuscitation would recommend it to others.462,463,465,471,472 Parents of chronically ill children are comfortable with medical equipment and emergency procedures, but even family members with no medical background who were at the side of a loved one to say goodbye during the final moments of life believe that their presence was beneficial to the patient,462–464,466,471–476 comforting for them,462–465,468–471,476 and helpful in their adjustment463–465,472,473,476,477 and grieving process.477 Standardized psychological examinations suggest that, compared with those not present, family members present during attempted resuscitations have less anxiety and depression and more constructive grieving behavior.477 Parents or family members often fail to ask, but healthcare providers should offer the opportunity in most situations.474,478,479 Whenever possible, provide family members with the option of being present during resuscitation of an infant or child (Class I, LOE B).474,478,479 Family presence during resuscitation, in general, is not disruptive, 464,472,475,476,480,481 and does not create stress among staff or negatively affect their performance.462,464,480,482 If the presence of family members creates undue staff stress or is considered detrimental to the resuscitation,483 then family members should be respectfully asked to leave (Class IIa, LOE C). Members of the resuscitation team must be sensitive to the presence of family members, and one person should be assigned to remain with the family to comfort, answer questions, and