Double (dual) sequential defibrillation for refractory ventricular fibrillation cardiac arrest: A systematic review

2023 International Consensus on Cardiopulmonary Resuscitation and Emergency Cardiovascular Care Science With Treatment Recommendations: Summary From the Basic Life Support; Advanced Life Support; Pediatric Life Support; Neonatal Life Support; Education, Implementation, and Teams; and First Aid Task Forces

The International Liaison Committee on Resuscitation engages in a continuous review of new, peer-reviewed, published cardiopulmonary resuscitation and first aid science. Draft Consensus on Science With Treatment Recommendations are posted online throughout the year, and this annual summary provides more concise versions of the final Consensus on Science With Treatment Recommendations from all task forces for the year. Topics addressed by systematic reviews this year include resuscitation of cardiac arrest from drowning, extracorporeal cardiopulmonary resuscitation for adults and children, calcium during cardiac arrest, double sequential defibrillation, neuroprognostication after cardiac arrest for adults and children, maintaining normal temperature after preterm birth, heart rate monitoring methods for diagnostics in neonates, detection of exhaled carbon dioxide in neonates, family presence during resuscitation of adults, and a stepwise approach to resuscitation skills training. Members from 6 International Liaison Committee on Resuscitation task forces have assessed, discussed, and debated the quality of the evidence, using Grading of Recommendations Assessment, Development, and Evaluation criteria, and their statements include consensus treatment recommendations. Insights into the deliberations of the task forces are provided in the Justification and Evidence-to-Decision Framework Highlights sections. In addition, the task forces list priority knowledge gaps for further research. Additional topics are addressed with scoping reviews and evidence updates.

2023 International Consensus on Cardiopulmonary Resuscitation and Emergency Cardiovascular Care Science With Treatment Recommendations: Summary From the Basic Life Support; Advanced Life Support; Pediatric Life Support; Neonatal Life Support; Education, Implementation, and Teams; and First Aid Task Forces

The International Liaison Committee on Resuscitation engages in a continuous review of new, peer-reviewed, published cardiopulmonary resuscitation and first aid science. Draft Consensus on Science With Treatment Recommendations are posted online throughout the year, and this annual summary provides more concise versions of the final Consensus on Science With Treatment Recommendations from all task forces for the year. Topics addressed by systematic reviews this year include resuscitation of cardiac arrest from drowning, extracorporeal cardiopulmonary resuscitation for adults and children, calcium during cardiac arrest, double sequential defibrillation, neuroprognostication after cardiac arrest for adults and children, maintaining normal temperature after preterm birth, heart rate monitoring methods for diagnostics in neonates, detection of exhaled carbon dioxide in neonates, family presence during resuscitation of adults, and a stepwise approach to resuscitation skills training. Members from 6 International Liaison Committee on Resuscitation task forces have assessed, discussed, and debated the quality of the evidence, using Grading of Recommendations Assessment, Development, and Evaluation criteria, and their statements include consensus treatment recommendations. Insights into the deliberations of the task forces are provided in the Justification and Evidence-to-Decision Framework Highlights sections. In addition, the task forces list priority knowledge gaps for further research. Additional topics are addressed with scoping reviews and evidence updates.

Defibrillation strategies for refractory ventricular fibrillation out-of-hospital cardiac arrest: A systematic review and network meta-analysis

BACKGROUND AND OBJECTIVE

Double sequential external defibrillation (DSED) and vector-change defibrillation (VCD) have been suggested to enhance clinical outcomes for patients with ventricular fibrillation (VF) refractory of standard defibrillation (SD). Therefore, this network meta-analysis aims to evaluate the comparative efficacy of DSED, VCD, and SD for refractory VF.

METHODS

A systematic review and network meta-analysis synthesizing randomized controlled trials (RCTs) and comparative observational studies retrieved from PubMed, EMBASE, WOS, SCOPUS, and Cochrane through November 15th, 2022. R software netmeta and netrank package (R version 4.2.0) and meta-insight software were used to pool dichotomous outcomes using odds ratio (OR) presented with the corresponding confidence interval (CI). Our protocol was prospectively published in PROSPERO with ID: CRD42022378533.

RESULTS

We included seven studies with a total of 1632 participants. DSED was similar to SD in survival to hospital discharge (OR: 1.14 with 95% CI [0.55, 2.83]), favorable neurological outcome (modified Rankin scale ≤2 or cerebral performance category ≤2) (OR: 1.35 with 95% CI [0.46, 3.99]), and return of spontaneous circulation (ROSC) (OR: 0.81 with 95% CI [0.43; 1.5]). In addition, VCD was similar to SD in survival to hospital discharge (OR: 1.12 with 95% CI [0.27, 4.57]), favorable neurological outcome (OR: 1.01 with 95% CI [0.18, 5.75]), and ROSC (OR: 0.88 with 95% CI [0.24; 3.15]).

CONCLUSION

Double sequential external defibrillation and VCD were not associated with enhanced outcomes in patients with refractory VF out-of-hospital cardiac arrest, compared to SD. However, the current evidence is still inconclusive, warranting further large-scale RCTs.

Keep shocking: Double sequential defibrillation for refractory ventricular fibrillation

Double sequential defibrillation is proposed as a novel modality of managing refractory ventricular fibrillation (VF). However, existing evidence has not been enough to support this. Here, we report an interesting case of a 54-year-old male who suffered from cardiac arrest with VF rhythm. The patient did not respond to 11 consecutive shocks along with antiarrhythmic medications. However, double sequential defibrillation terminated the VF. He had another episode of VF unresponsive to thirty minutes of standard defibrillation on his way to the catheterization laboratory. Again, the VF was terminated by double sequential defibrillation. Five days later, the patient was discharged home without neurological sequels.

Defibrillation Strategies for Refractory Ventricular Fibrillation

BACKGROUND

Despite advances in defibrillation technology, shock-refractory ventricular fibrillation remains common during out-of-hospital cardiac arrest. Double sequential external defibrillation (DSED; rapid sequential shocks from two defibrillators) and vector-change (VC) defibrillation (switching defibrillation pads to an anterior-posterior position) have been proposed as defibrillation strategies to improve outcomes in patients with refractory ventricular fibrillation.

METHODS

We conducted a cluster-randomized trial with crossover among six Canadian paramedic services to evaluate DSED and VC defibrillation as compared with standard defibrillation in adult patients with refractory ventricular fibrillation during out-of-hospital cardiac arrest. Patients were treated with one of these three techniques according to the strategy that was randomly assigned to the paramedic service. The primary outcome was survival to hospital discharge. Secondary outcomes included termination of ventricular fibrillation, return of spontaneous circulation, and a good neurologic outcome, defined as a modified Rankin scale score of 2 or lower (indicating no symptoms to slight disability) at hospital discharge.

RESULTS

A total of 405 patients were enrolled before the data and safety monitoring board stopped the trial because of the coronavirus disease 2019 pandemic. A total of 136 patients (33.6%) were assigned to receive standard defibrillation, 144 (35.6%) to receive VC defibrillation, and 125 (30.9%) to receive DSED. Survival to hospital discharge was more common in the DSED group than in the standard group (30.4% vs. 13.3%; relative risk, 2.21; 95% confidence interval [CI], 1.33 to 3.67) and more common in the VC group than in the standard group (21.7% vs. 13.3%; relative risk, 1.71; 95% CI, 1.01 to 2.88). DSED but not VC defibrillation was associated with a higher percentage of patients having a good neurologic outcome than standard defibrillation (relative risk, 2.21 [95% CI, 1.26 to 3.88] and 1.48 [95% CI, 0.81 to 2.71], respectively).

CONCLUSIONS

Among patients with refractory ventricular fibrillation, survival to hospital discharge occurred more frequently among those who received DSED or VC defibrillation than among those who received standard defibrillation. (Funded by the Heart and Stroke Foundation of Canada; DOSE VF ClinicalTrials.gov number, NCT04080986.).

Double sequential external defibrillation versus standard defibrillation in refractory ventricular fibrillation: A systematic review and meta-analysis

Introduction

Double sequential external defibrillation (DSED) in cardiopulmonary resuscitation has shown different results in comparison with standard defibrillation in the treatment of refractory ventricular fibrillation (RVF). This review aims to compare the advantages of DSED with standard defibrillation in the treatment of refractory ventricular fibrillation.

Materials and methods

PubMed, Embase, Web of Science, and Cochrane Library were searched from inception to May 1, 2022. Studies included adult patients who developed RVF. The study used random-effects and fixed-effects models for meta-analysis, which was reported by risk ratio (RR) with 95% confidence interval (CI), mean difference (MD), or standardized mean difference (SMD). The risk of bias in individual studies was assessed using the Robins-I tool for observational studies and the Cochrane Risk of Bias 2 (ROB-2) tool for clinical trials. Primary outcomes included the termination of RVF, prehospital return of spontaneous circulation (ROSC), survival to hospital admission, survival to hospital discharge, and good neurological recovery. Secondary outcomes included age, total defibrillation attempts, emergency medical system arrival time, and dose of epinephrine and amiodarone used.

Results

In this systematic review and meta-analysis, 10 studies containing 1347 patients with available data on treatment outcomes were included. The pooled estimate was (RR 1.03, 95% CI, 0.89 to 1.19; Z = 0.42, P = 0.678 > 0.05) for Termination of RVF, (RR 0.84, 95% CI, 0.63 to 1.11; Z = 1.23, P = 0.219 > 0.05) for ROSC, (RR 0.86, 95% CI, 0.69 to 1.06; Z = 1.4, P = 0.162 > 0.05) for survival to hospital admission, (RR 0.77, 95%CI, 0.52 to 1.15; Z = 1.26, P = 0.206 > 0.05) for survival to hospital discharge, (RR 0.65, 95%CI, 0.35 to 1.22; Z = 1.33, P = 0.184 > 0.05) for good neurologic recovery, (MD -1.01, 95%CI, -3.07 to 1.06; Z = 0.96, P = 0.34 > 0.05) for age, (MD 2.27, 95%CI, 1.80 to 2.73; Z = 9.50, P = 0.001 < 0.05) for total defibrillation attempts, (MD 1.10, 95%CI, -0.45 to 66; Z = 1.39, P = 0.16 > 0.05) for emergency medical system arrival time, (SMD 0.34, 95%CI, 0.17 to 0.50; Z = 4.04, P = 0.001 < 0.05) for epinephrine, and (SMD -0.30, 95%CI, -0.65 to -0.05; Z = 1.66, P = 0.1 > 0.05) for amiodarone.

Conclusion

We discovered no differences between DSED and standard defibrillation in termination of RVF, prehospital return of spontaneous circulation, survival to hospital admission, survival to hospital discharge, good neurological outcome, emergency medical system arrival time, and amiodarone doses in patients with RVF. There were some differences in the number of defibrillations and epinephrine doses utilized during resuscitation.

Systematic review registration

[https://www.crd.york.ac.uk/prospero/display_record.php?RecordID=329354], identifier [CRD42022329354].

New European Resuscitation Council guidelines for pediatric life support and their implications for pediatric anesthesia: An educational article

In this educational article, we summarize the changes in the new European Resuscitation Council guidelines for Pediatric Life Support, emphasizing the most important aspects for the anesthesiologist. Among these are: the use of two-thumb-encircling technique for thorax compressions in infants, 10 ml/kg as the standard volume fluid bolus and ventilation after intubation at an age-dependent rate. Using a fictitious case, we present a point-by-point summary of the changes and briefly mention some of the evidence behind them, referring the reader to the full guidelines for further evidence. We also give a summary of the incidence, causes, challenges, treatment, and prognosis of pediatric cardiac arrest in the operating room.

Combination of Multidisciplinary Therapies Successfully Treated Refractory Ventricular Arrhythmia in a STEMI Patient: Case Report and Literature Review

Ventricular fibrillation (VF) is a life-threatening cardiac arrhythmia that can lead to loss of cardiac function and sudden cardiac death. The most common cause of VF is ischemic cardiomyopathy, especially in the context of an acute coronary event. Prompt treatment with resuscitation and defibrillation can be lifesaving. Refractory VF, or pulseless ventricular tachycardia (pVT), refers to cases that do not respond to traditional advanced cardiac life-support (ACLS) measures, and it has a low survival rate. Some new life-saving interventions and novel techniques have been proposed as viable treatment options for patients presenting with refractory VF/pVT out-of-hospital cardiac arrest; these include extracorporeal membrane oxygenation (ECMO), esmolol, stellate ganglion block (SGB), and double sequential defibrillation (DSD). Recently, DSD has been discussed and used more frequently, but its survival rate is still not promising. We report a case of refractory VF caused by acute myocardial infarction that was treated with ACLS, DSD, ECMO, and cardiac catheterization in sequence, with a successful outcome.

Singapore Advanced Cardiac Life Support Guidelines 2021

Advanced cardiac life support (ACLS) emphasises the use of advanced airway management and ventilation, circulatory support and the appropriate use of drugs in resuscitation, as well as the identification of reversible causes of cardiac arrest. Extracorporeal cardiopulmonary resuscitation and organ donation, as well as special circumstances including drowning, pulmonary embolism and pregnancy are addressed. Resuscitation does not end with ACLS but must continue in post-resuscitation care. ACLS also covers the recognition and management of unstable pre-arrest tachy- and bradydysrhythmias that may deteriorate further.

[Adult advanced life support]

These European Resuscitation Council Advanced Life Support guidelines are based on the 2020 International Consensus on Cardiopulmonary Resuscitation Science with Treatment Recommendations. This section provides guidelines on the prevention of and ALS treatments for both in-hospital cardiac arrest and out-of-hospital cardiac arrest.

[Paediatric Life Support]

The European Resuscitation Council (ERC) Paediatric Life Support (PLS) guidelines are based on the 2020 International Consensus on Cardiopulmonary Resuscitation Science with Treatment Recommendations of the International Liaison Committee on Resuscitation (ILCOR). This section provides guidelines on the management of critically ill or injured infants, children and adolescents before, during and after respiratory/cardiac arrest.

European Resuscitation Council Guidelines 2021: Adult advanced life support

These European Resuscitation Council Advanced Life Support guidelines, are based on the 2020 International Consensus on Cardiopulmonary Resuscitation Science with Treatment Recommendations. This section provides guidelines on the prevention of and ALS treatments for both in-hospital cardiac arrest and out-of-hospital cardiac arrest.

European Resuscitation Council Guidelines 2021: Paediatric Life Support

These European Resuscitation Council Paediatric Life Support (PLS) guidelines, are based on the 2020 International Consensus on Cardiopulmonary Resuscitation Science with Treatment Recommendations. This section provides guidelines on the management of critically ill infants and children, before, during and after cardiac arrest.

Double external defibrillation for shock-refractory ventricular fibrillation cardiac arrest: A step towards standardization

Double (or dual) external defibrillation (DED) has increasingly been used in the last few years by a number of emergency medical services (EMS) as a last resort to terminate ventricular fibrillation and pulseless ventricular tachycardia in adult patients who remain refractory to standard defibrillation. However, no randomized controlled trials comparing DED with standard defibrillation focusing on patient-oriented outcomes as the primary objective have been published to date. Selection criteria, procedure techniques, and protocol are not clearly defined and vary across observational studies. The terms and/or nomenclature used to describe DED are confusing and vary throughout the literature. Despite increased use of DED, many questions remain as to which patients will derive the most benefit from DED, when to implement DED, and the optimal form of delivering DED. The present paper provides a brief overview of the background, procedure techniques, pad placement, and factors affecting how DED is delivered. A further objective of this paper is to offer a proposal for a uniform nomenclature and a standardized protocol in the form of a flowchart for EMS agencies to guide further clinical trials and best practices. This paper should not only help give background on novel definitions and clarify nomenclature for this practice, but more importantly should help institutions lay the groundwork for performing EMS-based large trials to further investigate the effectiveness of DED.

DOuble SEquential External Defibrillation for Refractory Ventricular Fibrillation (DOSE VF): study protocol for a randomized controlled trial

Background

Despite high-quality cardiopulmonary resuscitation (CPR), early defibrillation, and antiarrhythmic medications, some patients remain in refractory ventricular fibrillation (VF) during out-of-hospital cardiac arrest. These patients have worse outcomes compared to patients who respond to initial treatment. Double sequential external defibrillation (DSED) and vector change (VC) defibrillation have been proposed as viable options for patients in refractory VF. However, the evidence supporting the use of novel defibrillation strategies is inconclusive. The objective of this study is to compare two novel therapeutic defibrillation strategies (DSED and VC) against standard defibrillation for patients with treatment refractory VF or pulseless ventricular tachycardia (pVT) during out-of-hospital cardiac arrest.

Research question

Among adult (≥ 18 years) patients presenting in refractory VF or pulseless ventricular tachycardia (pVT) during out-of-hospital cardiac arrest, does DSED or VC defibrillation result in greater rates of survival to hospital discharge compared to standard defibrillation?

Methods

This will be a three-arm, cluster randomized trial with repeated crossover conducted in six regions of Ontario, Canada (Peel, Halton, Toronto, Simcoe, London, and Ottawa), over 3 years. All adult (≥ 18 years) patients presenting in refractory VF (defined as patients presenting in VF/pVT and remaining in VF/pVT after three consecutive standard defibrillation attempts during out-of-hospital cardiac arrest of presumed cardiac etiology will be treated by one of three strategies: (1) continued resuscitation using standard defibrillation, (2) resuscitation involving DSED, or (3) resuscitation involving VC (change of defibrillation pads from anterior-lateral to anterior-posterior pad position) defibrillation. The primary outcome will be survival to hospital discharge. Secondary outcomes will include return of spontaneous circulation (ROSC), VF termination after the first interventional shock, VF termination inclusive of all interventional shocks, and number of defibrillation attempts to obtain ROSC. We will also perform an a priori subgroup analysis comparing rates of survival for those who receive “early DSED,” or first DSED shock is shock 4–6, to those who receive “late DSED,” or first DSED shock is shock 7 or later.

Discussion

A well-designed randomized controlled trial employing a standardized approach to alternative defibrillation strategies early in the treatment of refractory VF is urgently required to determine if the treatments of DSED or VC defibrillation impact clinical outcomes.

Trial registration

ClinicalTrials.gov NCT04080986. Registered on 6 September 2019.

Supplementary information

The online version contains supplementary material available at 10.1186/s13063-020-04904-z.

A review of pre-hospital case series among those with time to double external defibrillation and neurologic outcomes

BACKGROUND

Double external defibrillation (DED) has been used as a final effort to terminate refractory ventricular fibrillation/pulseless ventricular tachycardiac (rVF/pVT). Data surrounding time to DED and patient-centered outcomes remains limited.

OBJECTIVES

This study summarizes patient-level data from case-series of observed survival and neurologic outcomes following the use of DED for rVF/pVT among those with data regarding time to DED.

METHODS

We conducted a literature search of PubMed, MEDLINE (OVID interface), and Scopus from January 1, 2000, through January 5, 2020. The literature was screened according to inclusion and exclusion criteria. Two investigators independently conducted the literature search, study selection, and data extraction.

RESULTS

Our database search identified 3139 records. Of these, 1660 studies were eliminated following inspection of the titles and 22 studies underwent full-text screening, three included in the final analysis, describing a total of 29 cases. All studies were considered to have critical risk of bias. For the critical outcomes of survival to discharge and neurologically intact survival we identified that patients who received DED before 30 min from collapse compared to those who received DED after 30 min had better survival to discharge (33.3% [5/15] vs. 7.1% [1/14]) and neurologically intact survival (20.0% [3/15] vs. 7.1% [1/14]). Overall, 20.6% of patients survived to discharge, 13.8% with neurologically intact survival. It is noteworthy that the patients who were discharged with a CPC of 1 received two, four, five, and three standard shocks before receiving DED, and the time between their onset of cardiac arrest to their first DED attempt was recorded to be 15, 26, 26, and 32 min, respectively.

CONCLUSION

We would like to indicate that there is not enough evidence to suggest that early use of pre-hospital DED is associated with improved outcomes. Further research should strive to address these issues before conclusions can be drawn.

Updates in Cardiac Arrest Resuscitation

There are approximately 350,000 out-of-hospital cardiac arrests and 200,000 in-hospital cardiac arrests annually in the United States, with survival rates of approximately 5% to 10% and 24%, respectively. The critical factors that have an impact on cardiac arrest survival include prompt recognition and activation of prehospital care, early cardiopulmonary resuscitation, and rapid defibrillation. Advanced life support protocols are continually refined to optimize intracardiac arrest management and improve survival with favorable neurologic outcome. This article focuses on current treatment recommendations for adult nontraumatic cardiac arrest, with emphasis on the latest evidence and controversies regarding intracardiac arrest management.