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: Jimena del Castillo and Dianne Atkins are co-authors on papers on this topic.
CoSTR Citation
Jason Acworth, Jimena del Castillo, Lokesh Tiwari, Dianne Atkins, Allan de Caen, on behalf of the International Liaison Committee on Resuscitation Pediatric Life Support Task Force. Energy doses for pediatric defibrillation during resuscitation - Paediatric Consensus on Science with Treatment Recommendations [Internet] Brussels, Belgium: International Liaison Committee on Resuscitation (ILCOR) Paediatric Advanced Life Support Task Force, 2025 January xxxxx. Available from: http://ilcor.org
Methodological Preamble and Link to Published Systematic Review
The continuous evidence evaluation process for the production of Consensus on Science with Treatment Recommendations (CoSTR) started with a systematic review (Acworth, 2023, PROSPERO CRD42024548898) conducted by the members of the PLS TF with involvement of clinical content experts. Evidence for pediatric literature was updated and considered by the Pediatric Life Support Task Force. Additional scientific literature was published after the completion of the systematic review and identified by the Pediatric Task Force and is described before the justifications and evidence to decision highlights section of this CoSTR. These data were taken into account when formulating the Treatment Recommendations.
Systematic Review
Acworth J et al. Energy doses for pediatric defibrillation during resuscitation (in preparation)
PICOST
The PICOST (Population, Intervention, Comparator, Outcome, Study Designs and Timeframe)
Population: Infants and children (excluding newborn children) who are in ventricular fibrillation or pulseless ventricular tachycardia during out-of-hospital or in-hospital cardiac arrest
Intervention: Initial defibrillation dose approximating 2J/kg (1.5-2.5 J/kg)
Comparators: Compared with initial defibrillation dose of >2.5J/kg, <1.5J/kg or any other specified dose
Outcomes: Survival to hospital discharge and return of spontaneous circulation (ROSC) were ranked as critical outcomes. Termination of VF/pVT was ranked as an important 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) and case series with a minimum of 5 number of cases were eligible for inclusion. Unpublished studies (e.g., conference abstracts, trial protocols) were excluded. All relevant publications in any language were included as long as there was an English abstract.
Timeframe: All years were included. The initial search was performed on 15 February 2024 and last updated on 1 September 2024.
PROSPERO Registration CRD42024548898
Consensus on Science
Seven studies were included in the systematic review.1-7 None of these provided clinical trial data. The identified studies were all observational studies and provided very low certainty evidence for the comparisons with the important and critical outcomes described.
All results are presented as Risk Ratios (RR) and absolute Risk Difference (aRD) and our assessment of statistical significance is based on the absolute risk reduction 95% confidence interval (CI 95%).
Studies comparing defibrillation dose <2 J/kg to defibrillation dose approximating 2 J/kg:
Survival to hospital discharge
For this critical outcome, we identified very low certainty data (downgraded for imprecision and risk of bias) from 2 cohort studies2,4 involving 225 patients which showed no significant difference to SHD associated with an initial defibrillation dose <2 J/kg compared to that approximating 2 J/kg (29 more survivors per 1,000 resuscitations; CI 95%: 96 fewer to 192 more).
Return of spontaneous circulation (ROSC)
For this critical outcome, we identified very low certainty data (downgraded for imprecision and risk of bias) from 4 cohort studies2,4,6,7 involving 266 patients which showed no significant difference to ROSC associated with defibrillation dose <2 J/kg compared to that approximating 2 J/kg (51 more survivors per 1,000 resuscitations; CI 95%: 42 fewer to 152 more).
Termination of VF/pVT
Additional very low certainty evidence (downgraded for imprecision and risk of bias) from two observational studies1,3 of 265 children found no significant effect on termination of VF/pVT associated with defibrillation dose <2 J/kg compared to that approximating 2 J/kg (179 fewer per 1,000; CI 95%: 415 fewer to 888 more).
Studies comparing defibrillation dose >2 J/kg to defibrillation dose approximating 2 J/kg:
Survival to hospital discharge
For this critical outcome, we identified very low certainty data (downgraded for imprecision and risk of bias) from 2 cohort studies2,4 involving 225 patients which showed no significant difference to SHD associated with defibrillation dose >2 J/kg compared to that approximating 2 J/kg (82 more survivors per 1,000 resuscitations; CI 95%: 253 fewer to 1000 more).
Return of spontaneous circulation (ROSC)
For this critical outcome, we identified very low certainty data (downgraded for imprecision and risk of bias) from 6 cohort studies2-7 involving 596 patients showing no significant difference to ROSC associated with defibrillation dose >2 J/kg compared to that approximating 2 J/kg (29 fewer survivors per 1,000 resuscitations; CI 95%: 133 fewer to 98 more).
Termination of VF/pVT
Additional very low certainty evidence (downgraded for imprecision and risk of bias) from two observational studies1,3 of 265 children found no significant effect on termination of VF/pVT associated with defibrillation dose >2 J/kg compared to that approximating 2 J/kg (22 fewer per 1,000; CI 95%: 99 fewer to 77 more).
Summary of findings
Acknowledging the very low level of certainty, the current available data suggest that the critical (SHD, ROSC) and important (termination of VF/pVT) outcomes are not significantly better or worse when initial defibrillation doses of <2 J/kg or >2 J/kg are used for children in cardiac arrest with a shockable rhythm (VF or pVT) compared with initial doses approximating 2 J/kg.
This review did not investigate the evidence for second and subsequent defibrillation dosages.
Treatment Recommendations
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].
Justification and Evidence to Decision Framework Highlights
Shockable ventricular arrhythmias (VF, pVT) are less frequently recorded in pediatric cardiac arrest but are associated with a higher survival rate than non-shockable rhythms (asystole, PEA). Early defibrillation is the foundation of treatment but optimal energy doses for initial and subsequent shocks remain controversial.
Differences remain in the first shock dose recommended by ILCOR member councils, with the ERC and ANZCOR recommending 4J/kg for the first and all subsequent shocks and the AHA recommending an initial dose of 2-4 J/kg (for ease of teaching, a dose of 2 J/kg is used in algorithms and training materials). For refractory VF, the AHA guidelines recommend increasing the defibrillation dose to 4 J/kg, suggesting that subsequent energy doses should be at least 4 J/kg and noting that higher levels may be considered, not to exceed 10 J/kg.
While a change in recommended initial dosing for pediatric defibrillation would be readily implementable, it is likely that local guidance will stay in place unless there is clear evidence to change. The task force also recognised that most of the studies were conducted in sites where either 2 J/kg or 4 J/kg doses were recommended for initial defibrillation. The variability of dosing was largely attributable to the limited number of energy dose settings on defibrillators. So, although no specific energy dose was found superior, energy selections would generally have been approximating either 2 or 4 J/kg.
EtD Table: PLS 4080 12 Et D Energy doses for pediatric defibrillation during resuscitation
Knowledge Gaps
Specific undesirable effects (outside of the lack of ROSC/SHD) were not consistently reported in the studies identified e.g. myocardial damage.
Prehospital and in-hospital studies, ideally comparing existing different dosing strategies with planned subgroup analyses based on patient age and type of shockable rhythm (primary vs secondary) are ethical, necessary, and critically important to help guide clinicians in making these complex decisions. As different resuscitation councils recommend either 2 or 4 J/kg as an initial defibrillation dose, this may provide an opportunity for an international comparative study.
Further examination of the potential adverse effects of higher defibrillation doses when fixed energy doses are provided (AEDs) would also be helpful.
Future studies would benefit from including outcome measures consistent with the P-COSCA recommendations.
References
1. Gutgesell HP, Tacker WA and Geddes LA. Energy dose for ventricular defibrillation of children. Pediatrics. 1976;58:898-901.
2. Hoyme DB, Zhou Y, Girotra S, Haskell SE, Samson RA, Meaney P, Berg M, Nadkarni VM, Berg RA, Hazinski MF, Lasa JJ and Atkins DL. Improved survival to hospital discharge in pediatric in-hospital cardiac arrest using 2 Joules/kilogram as first defibrillation dose for initial pulseless ventricular arrhythmia. Resuscitation. 2020;153:88-96.
3. Meaney PA, Nadkarni VM, Atkins DL, Berg MD, Samson RA, Hazinski MF and Berg RA. Effect of defibrillation energy dose during in-hospital pediatric cardiac arrest. Pediatrics. 2011;127:e16-23.
4. Rodríguez-Núñez A, López-Herce J, del Castillo J and Bellón JM. Shockable rhythms and defibrillation during in-hospital pediatric cardiac arrest. Resuscitation. 2014;85:387-91.
5. Rodríguez-Núñez A, López-Herce J, García C, Domínguez P, Carrillo A and Bellón JM. Pediatric defibrillation after cardiac arrest: initial response and outcome. Crit Care. 2006;10:R113.
6. Tibballs J, Carter B, Kiraly NJ, Ragg P and Clifford M. External and internal biphasic direct current shock doses for pediatric ventricular fibrillation and pulseless ventricular tachycardia. Pediatr Crit Care Med. 2011;12:14-20.
7. Tibballs J and Kinney S. A prospective study of outcome of in-patient paediatric cardiopulmonary arrest. Resuscitation. 2006;71:310-8.