Optimal Defibrillation Dose for Children

Written by Clay Smith

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For children with ventricular fibrillation or pulseless ventricular tachycardia (VF/pVT), a defibrillation dose of 2 J/kg was associated with the highest survival to discharge. Doses outside the range of 1.7-2.5 J/kg had lower survival.

Why does this matter?
For children with VF/pVT, PALS recommends a starting defibrillation dose of 2-4 J/kg and notes it is reasonable to repeat a shock of 4 J/kg if refractory. The European Resuscitation Council recommends a starting dose of 4 J/kg. Does it really matter if it’s a little higher or a little lower than 2 J/kg?

Not 2 much. Not 2 little.
This was a retrospective look at an AHA arrest database that included 301 children ≤12 years with in-hospital VF/pVT arrest. Children had an average age of about 3 years and most were in the PICU, had respiratory difficulty, hypotension, and were intubated. They adjusted for potential confounders and found that in children ≤12 years with VF/pVT, survival to discharge was worse when defibrillation doses were outside the range of 1.7 – 2.5 J/kg. Though not conclusive from this study, it seems that too high a dose may be worse than too low. For those ≤18 years (n=422) with VF, doses >2.5 J/kg were associated with lower survival to discharge. I wish we knew if this was neurologically intact survival to discharge. It seems to me, at least for now, that 2 J/kg is the right dose in pediatric patients with VF/pVT. I am now wary of overshooting. If faced with a pediatric VF/pVT arrest and an AED with no dose attenuator, I would still shock with what I had. But in-hospital, I think we need to fine tune this and get as close to 2 J/kg as possible.

Source
Improved survival to hospital discharge in pediatric in-hospital cardiac arrest using 2 Joules/kilogram as first defibrillation dose for initial pulseless ventricular arrhythmia. Resuscitation. 2020 Aug;153:88-96. doi: 10.1016/j.resuscitation.2020.05.048. Epub 2020 Jun 6.

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