Energy doses for paediatric defibrillation in cardiac arrest: systematic review and meta-analysis

Jason Acworth¹, Jimena Del Castillo², Lokesh Kumar Tiwari³, Dianne Atkins⁴, Allan de Caen⁵, Arun Bansal⁶, Thomaz Bittencourt Couto⁷, Stephan Katzenschlager⁸, Monica Kleinman⁹, Jesus Lopez-Herce², Ryan W Morgan¹⁰, Michelle Myburgh¹¹, Vinay Nadkarni¹², Janice A Tijssen¹³, Barnaby R Scholefield¹⁴; International Liaison Committee on Resuscitation Paediatric Life Support Task Force

Affiliations

¹ Emergency Department, Queensland Children's Hospital, Brisbane, Australia, Faculty of Medicine, University of Queensland, Australia.
² Paediatric Intensive Care Department, Hospital General Universitario Gregorio Maranon de Madrid, Spain.
³ Division of Pediatric Pulmonology and Intensive Care, Department of Paediatrics, All India Institute of Medical Sciences, Rishikesh, India.
⁴ Stead Family Department of Pediatrics, Carver College of Medicine, University of Iowa, Iowa City, IA 52242, USA.
⁵ Division of Pediatric Critical Care, University of Alberta, Edmonton, Canada.
⁶ Pediatric Critical Care Unit, Advanced Pediatric Center, Post Graduate Institute of Medical Education and Research, Chandigarh, India.
⁷ Centro de Simulação Realística and Faculdade Israelita de Ciências da Saúde, Hospital Israelita Albert Einstein AND Pronto Socorro, Instituto da Criança e do Adolescente do Hospital das Clínicas da Faculdade de Medicina da Universidade de São Paulo, Brazil.
⁸ Heidelberg University, Medical Faculty Heidelberg, Department of Anesthesiology, Heidelberg, Germany.
⁹ Department of Anesthesiology, Critical Care and Pain Medicine, Boston Children's Hospital and Harvard Medical School, Boston, USA.
¹⁰ Department of Anesthesia and Critical Care Medicine, Children's Hospital of Philadelphia, University of Pennsylvania Perelman School of Medicine, USA.
¹¹ Department of Paediatrics and Child Health, University of the Free State, Bloemfontein, South Africa.
¹² Department of Anesthesia and Critical Care Medicine Children's Hospital of Philadelphia, University of Pennsylvania Perelman School of Medicine, USA.
¹³ Children's Hospital, London Health Sciences Centre, Paediatric Critical Care Medicine, Department of Paediatrics, Western University, Canada.
¹⁴ Department of Paediatric Critical Care, Hospital for Sick Children, Toronto and University of Toronto, Canada.

PMID: 40524976
PMCID: PMC12169708
DOI: 10.1016/j.resplu.2025.100991

Review

Energy doses for paediatric defibrillation in cardiac arrest: systematic review and meta-analysis

Jason Acworth et al. Resusc Plus. 2025.

. 2025 May 26:24:100991.

doi: 10.1016/j.resplu.2025.100991. eCollection 2025 Jul.

Authors

Affiliations

¹ Emergency Department, Queensland Children's Hospital, Brisbane, Australia, Faculty of Medicine, University of Queensland, Australia.
² Paediatric Intensive Care Department, Hospital General Universitario Gregorio Maranon de Madrid, Spain.
³ Division of Pediatric Pulmonology and Intensive Care, Department of Paediatrics, All India Institute of Medical Sciences, Rishikesh, India.
⁴ Stead Family Department of Pediatrics, Carver College of Medicine, University of Iowa, Iowa City, IA 52242, USA.
⁵ Division of Pediatric Critical Care, University of Alberta, Edmonton, Canada.
⁶ Pediatric Critical Care Unit, Advanced Pediatric Center, Post Graduate Institute of Medical Education and Research, Chandigarh, India.
⁷ Centro de Simulação Realística and Faculdade Israelita de Ciências da Saúde, Hospital Israelita Albert Einstein AND Pronto Socorro, Instituto da Criança e do Adolescente do Hospital das Clínicas da Faculdade de Medicina da Universidade de São Paulo, Brazil.
⁸ Heidelberg University, Medical Faculty Heidelberg, Department of Anesthesiology, Heidelberg, Germany.
⁹ Department of Anesthesiology, Critical Care and Pain Medicine, Boston Children's Hospital and Harvard Medical School, Boston, USA.
¹⁰ Department of Anesthesia and Critical Care Medicine, Children's Hospital of Philadelphia, University of Pennsylvania Perelman School of Medicine, USA.
¹¹ Department of Paediatrics and Child Health, University of the Free State, Bloemfontein, South Africa.
¹² Department of Anesthesia and Critical Care Medicine Children's Hospital of Philadelphia, University of Pennsylvania Perelman School of Medicine, USA.
¹³ Children's Hospital, London Health Sciences Centre, Paediatric Critical Care Medicine, Department of Paediatrics, Western University, Canada.
¹⁴ Department of Paediatric Critical Care, Hospital for Sick Children, Toronto and University of Toronto, Canada.

PMID: 40524976
PMCID: PMC12169708
DOI: 10.1016/j.resplu.2025.100991

Abstract

Background: Early defibrillation is the foundation of treatment of shockable ventricular arrhythmias (VF, pVT) but optimal energy doses for initial and subsequent shocks in paediatric cardiac arrest remain controversial.

Objectives: To assess the use of different energy doses for initial defibrillation in infants, children and adolescents with ventricular fibrillation (VF) or pulseless ventricular tachycardia (pVT) during cardiac arrest.

Methods: A systematic review was performed by the ILCOR Paediatric Life Support Task force. This systematic review was prospectively registered as PROSPERO CRD42024548898. A search of PubMed, EMBASE, and Cochrane Controlled Register of Trials (CENTRAL) was performed for clinical trials and observational studies, published before 1 January 2025, involving cardiac defibrillation in infants and children (excluding newborn infants) in cardiac arrest. Investigators reviewed studies for relevance, extracted data, and assessed risk of bias using the ROBINS-I framework. Critical outcomes included survival to hospital discharge and return of spontaneous circulation. Results were compiled into a Summary of Findings table using the GRADEpro Guideline Development tool. Statistical calculations and Forest plot generation were performed using RevMan.

Results: We identified 7 relevant observational studies. The majority of studies involved in-hospital cardiac arrest. The overall certainty of evidence was very low. Critical (survival to hospital discharge, return of spontaneous circulation) and important (termination of VF/pVT) outcomes were not significantly better or worse when initial defibrillation doses of <1.5 J/kg or >2.5 J/kg were used for children in cardiac arrest with a shockable rhythm compared with initial doses approximating 2 J/kg.

Conclusions: The current available data suggest that outcomes are not significantly better or worse when initial defibrillation doses of <1.5 J/kg or >2.5 J/kg are used for children in cardiac arrest with a shockable rhythm (VF or pVT) compared with initial doses approximating 2 J/kg. Well-designed randomised trials are needed to address this important question.

Keywords: Cardiac arrest; Cardioversion; Defibrillation; Dose; Paediatric.

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Conflict of interest statement

The authors declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper. Monica Kleinman serves on the Editorial Board of the Resuscitation Journal. She was not involved in the editorial review or the decision to publish this article.

Figures

**Fig. 1**
PRISMA Diagram for systematic review.

**Fig. 2**
**Forest plots for defibrillation dose <1.5 J/kg compared to defibrillation dose approximating 2 J/kg. M−H**: Cochran-Mantel-Haenszel. 95% CI: 95 percent confidence interval.

**Fig. 3**
**Forest plots for defibrillation dose >2.5 J/kg compared to defibrillation dose approximating 2 J/kg. M−H**: Cochran-Mantel-Haenszel. 95% CI: 95 percent confidence interval.

See this image and copyright information in PMC

References

1. Atkins D.L., Everson-Stewart S., Sears G.K., et al. Epidemiology and outcomes from out-of-hospital cardiac arrest in children: the Resuscitation Outcomes Consortium Epistry-Cardiac Arrest. Circulation. 2009;119:1484–1491. [Resuscitation Outcomes Consortium I] - PMC - PubMed
1. Van de Voorde P., Turner N.M., Djakow J., et al. European Resuscitation Council Guidelines 2021: paediatric life support. Resuscitation. 2021;161:327–387. - PubMed
1. ANZCOR. Guideline 12.2 – Paediatric Advanced Life Support (PALS); 2021. Available at: https://www.anzcor.org/home/paediatric-advanced-life-support/guideline-1....
1. Topjian A.A., Raymond T.T., Atkins D., et al. Part 4: pediatric basic and advanced life support: 2020 American Heart Association Guidelines for Cardiopulmonary Resuscitation and Emergency Cardiovascular Care. Circulation. 2020;142:S469–S523. - PubMed
1. Mercier E., Laroche E., Beck B., et al. Defibrillation energy dose during pediatric cardiac arrest: systematic review of human and animal model studies. Resuscitation. 2019;139:241–252. - PubMed

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Energy doses for paediatric defibrillation in cardiac arrest: systematic review and meta-analysis

Affiliations

Energy doses for paediatric defibrillation in cardiac arrest: systematic review and meta-analysis

Authors

Affiliations

Abstract

Conflict of interest statement

Figures

References

Publication types

LinkOut - more resources

Full Text Sources