Clinical paperSurvival 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
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.
References (39)
- et al.
European Resuscitation Council guidelines for resuscitation 2015: section 3. Adult advanced life support
Resuscitation
(2015) - et al.
Manual vs. integrated automatic load-distributing band CPR with equal survival after out of hospital cardiac arrest. The randomized CIRC trial
Resuscitation
(2014) - et al.
Design of the Circulation Improving Resuscitation Care (CIRC) trial: a new state of the art design for out-of-hospital cardiac arrest research
Resuscitation
(2011) - et al.
Why Norwegian 2005 guidelines differs slightly from the ERC guidelines
Resuscitation
(2007) - et al.
Transthoracic impedance used to evaluate performance of cardiopulmonary resuscitation during out of hospital cardiac arrest
Resuscitation
(2008) - et al.
Effect of adrenaline on survival in out-of-hospital cardiac arrest: a randomised double-blind placebo-controlled trial
Resuscitation
(2011) - et al.
Adrenaline for out-of-hospital cardiac arrest resuscitation: a systematic review and meta-analysis of randomized controlled trials
Resuscitation
(2014) - et al.
Adrenaline in out-of-hospital ventricular fibrillation. Does it make any difference?
Resuscitation
(1995) - et al.
A prospective, randomised and blinded comparison of first shock success of monophasic and biphasic waveforms in out-of-hospital cardiac arrest
Resuscitation
(2003) - et al.
Effects of compression depth and pre-shock pauses predict defibrillation failure during cardiac arrest
Resuscitation
(2006)
Retrospective evaluation of current-based impedance compensation defibrillation in out-of-hospital cardiac arrest
Resuscitation
European Resuscitation Council guidelines for resuscitation 2010 section 3. Electrical therapies: automated external defibrillators, defibrillation, cardioversion and pacing
Resuscitation
Changes in transthoracic impedance during sequential biphasic defibrillation
Resuscitation
Defibrillation probability and impedance change between shocks during resuscitation from out-of-hospital cardiac arrest
Resuscitation
Current is better than energy as predictor of success for biphasic defibrillatory shocks in a porcine model of ventricular fibrillation
Resuscitation
Pre-shock chest compression pause effects on termination of ventricular fibrillation/tachycardia and return of organized rhythm within mechanical and manual cardiopulmonary resuscitation
Resuscitation
Implementation of a standardised treatment protocol for post resuscitation care after out-of-hospital cardiac arrest
Resuscitation
European Resuscitation Council and European Society of Intensive Care Medicine guidelines for post-resuscitation care 2015: section 5 of the European Resuscitation Council guidelines for resuscitation 2015
Resuscitation
BIPHASIC trial: a randomized comparison of fixed lower versus escalating higher energy levels for defibrillation in out-of-hospital cardiac arrest
Circulation
Cited by (8)
Protocol for a cluster randomised controlled feasibility study of Prehospital Optimal Shock Energy for Defibrillation (POSED)
2022, Resuscitation PlusCitation Excerpt :Our recent systematic review identified a recent post-hoc analysis of the CIRC trial, comparing manual and mechanical chest compression delivery, which explored the effect of shock strategy.12 No difference in long-term survival was detected between patients receiving escalating energy shocks (200–300–360 J) and those receiving fixed high-energy shocks (360–360–360 J) (unadjusted risk ratio 0.99, 95% CI 0.73, 1.23).13 However, no strong conclusions can be drawn due to the post-hoc non-randomised nature of the analysis.
Effectiveness of alternative shock strategies for out-of-hospital cardiac arrest: A systematic review
2022, Resuscitation PlusCitation Excerpt :Findings are summarised in Appendix A8. Olsen et al.33 found no significant difference in survival to hospital discharge (unadjusted risk ratio 0.99, 95% CI 0.73, 1.23) in the escalating energy group (27.5%, 70/255) compared to the fixed high-energy group (27.6%, 132/478). Study authors took account of clustering by site by including the site as a random effect in the analysis.
European Resuscitation Council Guidelines 2021: Adult advanced life support
2021, ResuscitationCitation Excerpt :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
Shorter defibrillation interval promotes successful defibrillation and resuscitation outcomes
2019, ResuscitationCitation Excerpt :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.
Defibrillation Strategies for Refractory Ventricular Fibrillation
2023, New England Journal of Medicine