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

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.

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.