Elsevier

Resuscitation

Volume 136, March 2019, Pages 112-118
Resuscitation

Clinical paper
Survival to hospital discharge with biphasic fixed 360 joules versus 200 escalating to 360 joules defibrillation strategies in out-of-hospital cardiac arrest of presumed cardiac etiology

https://doi.org/10.1016/j.resuscitation.2019.01.020Get rights and content

Abstract

Introduction

Guidelines recommend constant or escalating energy levels for shocks after the initial defibrillation attempt. Studies comparing survival to hospital discharge with escalating vs fixed high energy level shocks are lacking. We compared survival to hospital discharge for 200 J escalating to 360 J vs fixed 360 J in patients with initial ventricular fibrillation/pulseless ventricular tachycardia in a post-hoc analysis of the Circulation Improving Resuscitation Care trial database.

Methods and Results

Pre-shock rhythm, rhythm 5 s after shock, shock energy levels, termination of ventricular fibrillation/pulseless ventricular tachycardia (TOF), and survival to hospital discharge were recorded. Association between defibrillation strategy and survival to hospital discharge was investigated with multivariable logistic regression. The escalating energy group included 260 patients and 883 shocks vs 478 patients and 1736 shocks in the fixed-high energy group. There was no difference in survival to hospital discharge between escalating (70/255 patients, 28%) and fixed energy group (132/478 patients, 28%) (unadjusted OR 1.00, 95% CI 0.72–1.42 and adjusted OR 0.81, 95% CI 0.54–1.22, p = 0.32). First shock TOF was 86% in the escalating group compared to 83% in the fixed-high group, p = 0.27.

Conclusion

There was no difference in survival to hospital discharge or the frequency of TOF between escalating energy and fixed-high energy group.

ClinicalTrials.gov Identifier: NCT00597207.

Introduction

In patients requiring defibrillation the BIPHASIC trial1 compared termination of ventricular fibrillation (VF) and restoration of organized rhythm for fixed lower-energy (150 J) vs escalating higher energy (200–300–360 J) using defibrillators with biphasic truncated exponential waveform (BTE) technology. They concluded that patients requiring multiple shocks could benefit from higher energy levels using the escalating energy strategy.

The 2015 European Resuscitation Council (ERC) guidelines state that “both strategies are acceptable; however, if the first shock is not successful and the defibrillator is capable of delivering shocks of higher energy, it is reasonable to increase the energy for subsequent shocks.”2 and “If a shockable rhythm recurs after successful defibrillation with ROSC, and the defibrillator is capable of delivering shocks of higher energy, it is reasonable to increase the energy for subsequent shocks.”2

The 2015 American Heart Association (AHA) guidelines4 state that “selection of fixed vs escalating energy for subsequent shocks be based on the specific manufacturer’s instructions” (Class IIa, level of evidence (LOE)) C-limited data (LD) and “If using a manual defibrillator capable of escalating energies, higher energy for second and subsequent shocks may be considered (Class IIb, LOE C-LD)”. These statements indicate that the optimal energy level (fixed low-, escalating-, or fixed high-energy) of the first and subsequent biphasic defibrillation attempts are not firmly established.

To add to the knowledge base, we have investigated how biphasic defibrillation technology with escalating energy levels compared with fixed high-energy levels (360 J) influenced rates of termination of VF/ventricular tachycardia (VT) (TOF) and survival to hospital discharge in a post-hoc cohort study based on the Circulation Improving Resuscitation Care trial (CIRC) database.

Section snippets

Study population

CIRC5 was a multicenter, randomized, controlled trial of manual cardiopulmonary resuscitation (CPR) vs manual CPR integrated with a mechanical load-distributing band (LDB) device (AutoPulse® (ZOLL Medical, Chelmsford, MA) in emergency medical services (EMS) treated adult patients with cardiac arrest of presumed cardiac etiology. Patients treated by both basic and advanced life support units between March 5, 2009 and January 11, 2011 were eligible for analysis if they had initial VF/VT and

Results

In CIRC 1657 (39%) of 4231 patients received shocks with analyzable defibrillator data. A total of 912 patients had initial VF/VT, and we were able to categorize 752 of them into an escalating or a fixed high-energy group. One site had no LP500/12/15 and were excluded from analysis (n = 14). In the escalating energy group 260 patients received 913 shocks and in the fixed high-energy group 478 patients received 1765 shocks (Fig. 1). Consensus on post-shock rhythm was not reached for 59 shocks

Discussion

This is the first clinical study of escalating vs fixed high-energy level biphasic defibrillation strategies. There was no difference in survival to hospital discharge, 24-h survival, or rate of termination of VF/VT with shocks. The secondary outcome, survival to ED, was lower in the escalating compared with the fixed high-energy group only in the unadjusted analysis.

A higher rate of ED admittance with ROSC is beneficial if it increases the number of patients discharged from hospital with good

Limitations

The original CIRC study was not randomized for escalating vs fixed high-energy defibrillation, but for two chest compression strategies.5 The present study is post-hoc analysis of data from one study site, which had implemented a fixed high-energy strategy vs three other sites in CIRC with escalating energy strategies.5 Post-resuscitation care with a documented effect on survival was not standardized.16, 36, 37 The high energy site’s survival to hospital discharge did not show a significant

Conclusion

There was no difference in survival to hospital discharge or the secondary outcomes rates of TOF and 24-h survival when adjusted for covariates between the fixed high-energy and the escalating energy groups. This post-hoc non-randomized analysis should be interpreted with caution.

Acknowledgements

The authors would like to acknowledge all of the EMS providers and thanks to the coordinators and monitors at each of the participating sites for their careful and persistent work with the data collection. A special thanks to Petter A. Steen for valuable critique related to the manuscript, and Håvard W. Kongsgård with help on the mixed model analysis.

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      First shock efficacy of the RLB waveform using 120 J has been reported as 85%.201 Four studies have suggested equivalence with lower and higher starting energy biphasic defibrillation.202–205 although one has suggested that initial low energy (150 J) defibrillation is associated with better survival.206

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      However, one study demonstrated that myocardial dysfunction after multiple defibrillation was induced by a reduction in myocardial perfusion rather than the cumulative energy of defibrillation.16 Furthermore, recent clinical studies have shown that the cumulative dose of defibrillation was not associated with resuscitation outcomes, a result similar to that shown in our study.17,18 Therefore, it would be better to focus on early termination of VF/pulseless VT irrespective of the frequency or cumulative energy of defibrillation to promote better resuscitation outcomes.

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