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Re-DOSE VF… DSED for Shock-Refractory VF?

June 17, 2024

Written by Amanda Mathews

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This secondary analysis of the DOSE VF trial found that DSED (dual sequence external defibrillation) was the superior strategy for obtaining ROSC and functional neurologic outcome regardless of whether the patient was in recurrent VF or shock-refractory VF after three standard defibrillation shocks.

Time for a re-DOSE
The original publication of the DOSE VF trial showed that alternative defibrillation strategies of DSED and vector change (anterior-posterior pad placement) defibrillation demonstrated a survival benefit for patients compared to standard defibrillation for recurrent VF. There was no attempt to distinguish outcomes between recurrent VF (absence of VF for at least 5 seconds followed by spontaneous recurrence) and shock-refractory VF (continuous VF after first 3 shocks). There are studies showing that patients with shock-refractory VF have high mortality (97%) when treated with standard defibrillation only.

Researchers performed a secondary analysis of the original DOSE VF trial. 405 patients were in the original trial and after exclusions 345 were included in the secondary analysis. 60 patients (17%) were deemed to be in shock-refractory VF and 285 (83%) were deemed to be in recurrent VF. Patients characterized as being in recurrent VF had higher rates of survival to hospital discharge compared to shock-refractory VF.

DSED was found to be superior to standard defibrillation for survival overall and specifically for the shock-refractory group; no patient in shock refractory VF survived to hospital discharge using standard defibrillation. DSED was also superior to standard defibrillation for ROSC and neurologic survival for both sub-groups. Vector change defibrillation was not found to be superior to standard defibrillation overall or in either of the subgroups for survival.

How will this change my practice?
The DOSE VF trial was practice changing and gave me a new tool in my toolbox when treating a patient in what appears to be refractory VF. This secondary analysis further confirms that DSED is the superior strategy to terminate VF and obtain good neurologic outcomes for patients after three standard defibrillation shocks regardless of whether they are in recurrent or shock refractory VF.

The impact of alternate defibrillation strategies on shock-refractory and recurrent ventricular fibrillation: A secondary analysis of the DOSE VF cluster randomized controlled trial. Resuscitation. 2024 May;198:110186. doi: 10.1016/j.resuscitation.2024.110186. Epub 2024 Mar 24. PMID: 38522736.

What are your thoughts?