Conflict of Interest Declaration
The ILCOR Continuous Evidence Evaluation process is guided by a rigorous ILCOR Conflict of Interest policy. The following Task Force members and other authors were recused from the discussion as they declared a conflict of interest: none applicable
The following Task Force members and other authors declared an intellectual conflict of interest and this was acknowledged and managed by the Task Force Chairs and Conflict of Interest committees: none applicable
Task Force Scoping Review Citation
Reis A, Couto TB, Atkins DL,, Maconochie I, Aicken R, Bingham R, de Caen A, Guerguerian AM, Nadkarni V, Ng KC, Nuthall G, Ong G, Schexynader S, Tijssen J , Van de Voorde P. on behalf of the International Liaison Committee on Resuscitation Paediatric Life Support Task Force. Energy dose for pediatric shockable rhythms. Pediatric Life Support Task Force Insights [Internet] Brussels, Belgium: International Liaison Committee on Resuscitation (ILCOR) Education, Implementation, and Teams Task Force, 2020 January 09. Available from: http://ilcor.org
Methodological Preamble and Link to Published Scoping Review
The continuous evidence evaluation process started with a scoping review of ENERGY DOSE FOR PEDIATRIC SHOCKABLE RHYTHMS, conducted by the ILCOR PLS Task Force Scoping Review team. Evidence for pediatric literature was sought and considered by the Pediatric Task Force.
Scoping Review
No published review at this time
PICOST
Population: infants and children who are in VF or pVT in any setting
Intervention: a specific energy dose or regimen of energy doses for the initial or subsequent defibrillation attempt(s)
Comparators: 2 to 4 J/kg
Outcomes: harm to patient, ROSC, hospital discharge, long term survival, survival with good neurological outcome
Study Designs:
Randomized controlled trials (RCTs) and non-randomized studies (non-randomized controlled trials, interrupted time series, controlled before-and-after studies, cohort studies) that concern directly the population and intervention described above are eligible for inclusion. If it is anticipated that there will be insufficient studies from which to draw a conclusion, case series may be included in the initial search. The minimum number of cases for a case series to be included can be set by the ESR after discussion with the priority team or taskforce. Unpublished studies (e.g., conference abstracts, trial protocols) are excluded.
Timeframe: All literature from 2014 and all languages are included, as long as there is an English abstract
Active and Reposed PICOs Related to scope of work for this PICOST:
Peds 405 Energy doses for defibrillation (2015)
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2015 Consensus on Science: |
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For the critical outcome of survival to hospital discharge, we identified very-low-quality evidence from 3 pediatric observational studies of IHCA and OHCA (downgraded for indirectness, imprecision, and serious risk of bias){Berg 2005 63; Rossano 2006 80; Rodriguez-Nunez 2014 387} of 108 subjects showing no advantage to 2 to 4 J/kg as an initial defibrillation dose over any other specific energy dose (possible absolute effect size range, 18.5%–6.5%). For the important outcome of termination of VF/ pVT, we identified very-low-quality evidence from 2 pediatric observational studies of IHCA{Gutgesell 1976 898} and OHCA.{Berg 2005 63} Conversion from VF was demonstrated in both studies with either 2 J/kg{Gutgesell 1976 898} or 2 to 4 J/kg.{Berg 2005 63} For the important outcome of ROSC, we identified very-low-quality evidence from 1 pediatric observational study of IHCA (downgraded for indirectness, imprecision, and serious risk of bias){Rodriguez-Nunez 2014 387-391} of 40 subjects, showing no benefit to a specific energy dose for initial defibrillation (P=0.11). In addition, we identified very-low-quality evidence from 1 pediatric observational study of IHCA (downgraded for imprecision and serious risk of bias){Meaney 2011 e16} of 285 subjects showing that an initial shock of greater than 3 to 5 J/kg is less effective than 1 to 3 J/kg (OR, 0.42; 95% CI, 0.18–0.98; P=0.04). We did not identify any evidence to address the critical outcome of survival at 1 year or the important outcome of harm to patient. |
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2015 Treatment Recommendation: |
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We suggest the routine use of an initial dose of 2 to 4 J/kg of monophasic or biphasic defibrillation waveforms for infants or children in VF or pVT cardiac arrest (weak recommendation, very-low-quality evidence). There is insufficient evidence from which to base a recommendation for second and subsequent defibrillation dosages. |
Search Strategies
PUBMED (last searched: 10/30/2019)
(ventricular fibrillation[MeSH Terms]) OR electric defibrillation[MeSH Terms]) AND ("last 5 years"[PDat] AND Humans[Mesh] AND (infant[MeSH] OR child[MeSH] OR adolescent[MeSH])
References found: 226
Accepted: 8 for full text review. One of them (pediatric systematic review) addresses the question directly and was included in analyses. The others were included in background and narrative sections.
EMBASE (last searched: 10/30/2019)
(defibrillator:ab,ti OR 'heart fibrillation':ab,ti OR defibrillation:ab,ti) AND [2014-2019]/py AND ([infant]/lim OR [child]/lim OR [preschool]/lim OR [school]/lim OR [adolescent]/lim)
References found: 798
Accepted: no new references
COCHRANE (last searched: 10/30/2019)
Cochrane Reviews matching "defibrillation" in Title Abstract Keyword OR "ventricular fibrillation" in Title Abstract Keyword - (Word variations have been searched)
References found: 15
Accepted: none
Inclusion and Exclusion Criteria
Inclusion criteria:
Age< 18 years
Meet methodological inclusion criteria above.
Exclusion includes:
1/ Newborn at Delivery
2/ articles before 2014
3/animal studies
4/ Unpublished studies (e.g., conference abstracts, trial protocols)
Data tables
One Pediatric Study was identified = Systematic Review on energy dose:
Defibrillation energy dose during pediatric cardiac arrest: systematic review of human and animal model studies. (Mercier 2019, 241}
This review included 20 pediatric studies (human=10 and animal = 10) published from 1976 to 2014. The data on table is related only to human studies.
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Table 1 Pediatric study ENERGY DOSE FOR SHOCKABLE RHYTHMS |
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Author, year |
Design, Country |
Population |
Intervention /Comparator |
Main findings |
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Mercier 2019, 241 |
Systematic Review Eligibility criteria: Cohort or RCT; 30days to 18 years old patients; OHCA and IHCA; non trauma patients. Prospective and retrospective. The objectives were to determine the initial defibrillation energy dose for VF or pVT that is associated to sustained ROSC (main), any ROSC, survival, survival with favorable neurological outcomes, total energy dose, myocardial functional and defibrillation-induced complications |
10 human studies on pediatric cardiac arrest. |
Different defibrillation energy doses:(monophasic and biphasic) |
Were included 6 prospective and 4 retrospective observational studies. Median number of patients included in each study was 46 (11 to 266). IHCA was reported in 7, OHCA in 2 and both in 1 study. Monophasic waveform was performed in 5, biphasic in 2 and one or another in 2 studies. Four studies reported how the weight was obtained (retrieved from hospital record, autopsy or used the percentile of growth chart. There were substantial variations in initial defibrillation doses (0.1J/Kg to 14.3J/Kg) among studies. There was not a statistically significant association between the initial defibrillation dose and the rate of sustained ROSC (n=7) or survival (n=6). One study reported lower chance of sustained ROSC with 3-5J/kg as the initial defibrillation dose in a subgroup analysis OR: 0.40 (95%CI: 0.21-0.81) compared to higher and lower doses. Other studies showed no difference between successful energy dose. One study reported that a second shock was more likely with the first dose <2J/kg and other that the use of lower dose was associated with unsuccess. Smaller body weight seemed to be associated with a higher defibrillation threshold in two studies. No association was found between initial or cumulative energy and survival to hospital discharge. No association was reported between energy dosing and long-term survival or survival with good neurological outcome. One study showed that the number of shocks was inversely associated to long term survival. A second shock of >2 J/kg was less successful than 2J/kg in one study. Two studies that reported outcomes with monophasic and biphasic waveform found no difference. There was no association between energy dosing and complications related do defibrillation in one human study that looked to that. Meta-analysis was not possible due to clinical heterogeneity (population included, resuscitation protocols, defibrillator used, type of waveform). Risk of bias was moderate: VF/pVT as initial or subsequent rhythm, delay to start CPR and defibrillation, CA witnessed or not. |
Task Force Insights
1. Why this topic was reviewed.
In 2015 guidelines ILCOR recommended 2 to 4 joules/ kg, as the first shock, to treat shockable rhythms in pediatric cardiac arrest. Resuscitation councils’ orientations differ from one another. ERC recommends 4J/kg as the initial dose without escalation for subsequent shocks. AHA recommends 2-4 J/Kg, increasing to ≥ 4 J/Kg with subsequent shocks up to adult dose. In fact, the optimal energy dose for successful defibrillation in children is not known. Researchers are increasingly suggesting that 2J/kg maybe an ineffective initial defibrillation dose, however without a definitive study there has been hesitancy to modify this initial dose. {Egan 2013 134}
2. Narrative summary of evidence identified
Only one study was identified by the review: a systematic review of previously published studies {Mercier 2019 241}. This review included 10 human and 10 animal studies, all published before 2014 The review addresses the association of the initial defibrillation energy dose for VF or pVT with differing outcomes: any ROSC, sustained ROSC, survival, survival with favorable neurological outcomes, cumulative energy delivered, myocardial function and defibrillation-induced complications; escalating or fixed energy dose regimens were also analyzed. Human and pediatric animal studies were included.
The main findings were:
- There was not a statistically significant association between the initial defibrillation dose and sustained ROSC (n=7 studies) or survival (n=6 studies).
- One study reported lower chance of sustained ROSC with 3-5J/kg as the initial defibrillation dose in a subgroup analysis OR: 0.40 (95%CI: 0.21-0.81) compared to higher and lower doses. One study reported that a second shock was more likely with the first dose <2J/kg and other that the use of lower dose was associated with no ROSC.
- No association was found between initial or cumulative energy and survival to hospital discharge.
- No association was reported between energy dosing and long-term survival or survival with good neurological outcome.
- One study showed that the number of shocks was inversely associated to long term survival.
- A second shock of >2 J/kg was less successful than 2J/kg in one study.
- There was no association between energy dosing and complications related to defibrillation in one human study that looked to that.
3. Narrative Reporting of the task force discussions
The energy dose for defibrillation in pediatric advanced life support is a topic that has been discussed by ILCOR in 2010 and 2015. This scoping review has not identified sufficient new evidence to prompt either a new systematic review or reconsideration of current resuscitation guidelines/treatment recommendations.
Pulseless shockable rhythms are more common in adults than in children and vary according to the age. Pediatric OHCA studies have shockable rhythms in less than 10% { Li 2010 310; Fukuda 2017 111; Matsui 2019 150}. VF or pVT as the initial rhythm in pediatric IHCA is observed in 5-24% of pediatric cardiac arrests {Nadkarni 2006 50}. The low frequency of these rhythms contributes to the lack of information on pediatric defibrillation.
A successful defibrillation demands good performance and knowledge of particular steps. Pediatric prehospital EMS is sometimes not adequately prepared for pediatric defibrillation {Kaku 2016, 356}. Health professionals’ defibrillation skills were found to be poor in a tertiary care children’s hospital and factors related to human and machine function were associated with delays in defibrillation {Bhalala 2018 107}.
The pediatric data have some biases that interfere on the analyses of the effect of energy dosing on CPR outcomes. Many variables such as defibrillation waveform (monophasic vs biphasic) cardiac arrest setting (OHCA or IHCA), difficulty in estimating child weight in emergency situations, level of professional training and skills and timing for defibrillation are important points to take in consideration on the analysis of the studies.
Knowledge Gaps
Knowledge Gaps Template for Task Force chairs
- It is very important to have more data especially RCT trials. However, it is important to note that RCTs are very difficult because of low incidence of shockable rhythms in pediatric cardiac arrest.
References
Bhalala, U. S., Balakumar, N., Zamora, M., &Appachi, E. (2018). Hands-On Defibrillation Skills of Pediatric Acute Care Providers During a Simulated Ventricular Fibrillation Cardiac Arrest Scenario. Frontiers in Pediatrics, 6. doi:10.3389/fped.2018.00107
Chan PS, Krumholz HM, Nichol G, Nallamothu BK; American Heart Association National Registry of Cardiopulmonary Resuscitation Investigators. Delayed time to defibrillation after in-hospital cardiac arrest. N Engl J Med. 2008;358(1):9-17.
Egan, J., Atkins, L. Defibrillation in children: why a range in energy dosing? CurrPediatr Rev. 2013;9(2):134-8.
Fukuda, T., Ohashi-Fukuda, N., Kobayashi, H., Gunshin, M., Sera, T., Kondo, Y., & Yahagi, N. (2017). Public access defibrillation and outcomes after pediatric out-of-hospital cardiac arrest. Resuscitation, 111, 1–7. doi:10.1016/j.resuscitation.2016.11.010
Kaku, N., Nitta, M., Muguruma, T., Tsukahara, K., Knaup, E., Nosaka, N., &Enomoto, Y. (2016). Targeted age, device deployment, and problems associated with pediatric defibrillation in pediatric prehospital emergency medical care settings in Japan. Acute Medicine & Surgery, 3(4), 356–359. doi:10.1002/ams2.194
Li CJ, Kung CT, Liu BM, et al. Factors associated with sustained return of spontaneous circulation in children after out-of-hospital cardiac arrest of noncardiac origin. Am J Emerg Med 2010;28:310–7.
Matsui, S., Kitamura, T., Sado, J., Kiyohara, K., Kobayashi, D., Kiguchi, T., … Sobue, T. (2019). Location of arrest and survival from out-of-hospital cardiac arrest among children in the public-access defibrillation era in Japan. Resuscitation. doi:10.1016/j.resuscitation.2019.04.045
Mercier, E., Laroche, E., Beck, B., Le Sage, N., Cameron, P. A., Émond, M., … Ouellet-Pelletier, J. (2019). Defibrillation energy dose during pediatric cardiac arrest: systematic review of human and animal model studies. Resuscitation. doi:10.1016/j.resuscitation.2019.04.028
Mitani, Y., Ohta, K., Yodoya, N., Otsuki, S., Ohashi, H., Sawada, H., … Komada, Y. (2013). Public access defibrillation improved the outcome after out-of-hospital cardiac arrest in school-age children: a nationwide, population-based, Utstein registry study in Japan. EP Europace, 15(9), 1259–1266. doi:10.1093/europace/eut053
Nadkarni VM, Larkin GL, Peberdy MA, et al. First documented rhythm and clinical outcome from in-hospital cardiac arrest among children and adults. JAMA 2006;295:50–7.
Topjian, A. (2018). Shorter Time to Defibrillation in Pediatric CPR. JAMA Network Open, 1(5), e182653. doi:10.1001/jamanetworkopen.2018.2653
Valenzuela TD, Roe DJ, Cretin S, Spaite DW, Larsen MP. Estimating effectiveness of cardiac arrest interventions: a logistic regression survival model. Circulation. 1997;96(10):