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Energy Doses for Defibrillation

Question Type:
Intervention
Full Question:
Among infants and children who are in VF or pVT in any setting (P), does does a specific energy dose or regimen of energy doses for the initial or subsequent defibrillation attempt(s) (I), compared with compared with 2 to 4 J/kg (C), change Survival with Favorable neurological/functional outcome at discharge, 30 days, 60 days, 180 days AND/OR 1 year, ROSC;#103;#survival to hospital discharge, ROSC, harm to patient;#110;#termination of arrhythmia, ECG resolution (O)?
Consensus on Science:
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, 63-67; Rossano 2006, 80-89; Rodriguez-Nunez 2014, 387-391) 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, 898-901) and OHCA.(Berg 2005, 63-67) Conversion from VF was demonstrated in both studies with either 2 J/kg(Gutgesell 1976, 898-901) or 2 to 4 J/kg.(Berg 2005, 63-67) 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.
Treatment Recommendation:
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. Values, Preferences, and Task Force Insights In making these recommendations, we place a higher value on immediate defibrillation of a shockable rhythm over delaying defibrillation to select a specific dose that is not supported by scientific evidence. In addition, there are differing existing recommendations among the world’s resuscitation councils that span the 2 to 4 J/kg recommendations, without strong evidence for one dose over the other. Practical considerations must be weighed when contemplating a change to pediatric defibrillation guidelines. Considerable challenges exist when attempting to reach and teach a broad spectrum of healthcare personnel using newly created educational materials, as well as the necessary resetting of targets for clinical audit. When faced with limited data, the risk-benefit assessment of changing to a different energy dose may be outweighed by maintaining the current recommendations.
CoSTR Attachments:
Ped 405 Recommendations.doc    
Peds 405 SoF full table.doc    

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