Defibrillation Strategies for Refractory Ventricular Fibrillation
Defibrillation Strategies for Refractory Ventricular Fibrillation
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DOI：
10.1056/nejmoa2207304
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发表时间：
2022-11-06
影响因子：
158.5
通讯作者：
Scales, Damon C. C.
中科院分区：
文献类型：
--
作者：
Cheskes, Sheldon;Verbeek, P. Richard;Scales, Damon C. C.
背景尽管除颤技术取得了进步，但在院外心脏骤停期间，难治性心室颤动仍然很常见。双顺序外部除颤（DSED；两个除颤器的快速顺序电击）和矢量变换（VC）除颤（将除颤垫切换到前后位置）已被提议作为除颤策略，以改善难治性心室颤动患者的预后。方法我们在加拿大六个护理服务机构中进行了一项交叉的整群随机试验，以评估 DSED 和 VC 除颤与标准除颤的比较院外心脏骤停期间患有难治性心室颤动的成年患者。根据随机分配给护理人员服务的策略，使用这三种技术中的一种对患者进行治疗。主要结局是出院时的生存率。次要结局包括心室颤动终止、自主循环恢复和良好的神经系统结局，定义为出院时改良Rankin量表评分为2或更低（表明无症状至轻微残疾）。结果在数据和安全监测委员会因2019年冠状病毒病大流行而停止试验之前，总共入组了405名患者。共有 136 名患者 (33.6%) 被分配接受标准除颤，144 名患者 (35.6%) 接受 VC 除颤，125 名患者 (30.9%) 接受 DSED。 DSED 组的出院存活率比标准组更常见（30.4% 对比 13.3%；相对风险，2.21；95% 置信区间 [CI]，1.33 至 3.67），VC 组比标准组更常见（21.7% 对比 13.3%；相对风险，1.71；95% CI，1.01 至 3.67） 2.88）。与标准除颤相比，DSED（而非 VC 除颤）与较高比例的神经系统预后良好的患者相关（相对风险分别为 2.21 [95% CI，1.26 至 3.88] 和 1.48 [95% CI，0.81 至 2.71]）。 结论 在难治性心室颤动患者中，接受 DSED 的患者出院后存活率更高或 VC 除颤率高于接受标准除颤的患者。 （由加拿大心脏和中风基金会资助；DOSE VF ClinicalTrials.gov 编号，。）
BackgroundDespite advances in defibrillation technology, shock-refractory ventricular fibrillation remains common during out-of-hospital cardiac arrest. Double sequential external defibrillation (DSED; rapid sequential shocks from two defibrillators) and vector-change (VC) defibrillation (switching defibrillation pads to an anterior-posterior position) have been proposed as defibrillation strategies to improve outcomes in patients with refractory ventricular fibrillation.MethodsWe conducted a cluster-randomized trial with crossover among six Canadian paramedic services to evaluate DSED and VC defibrillation as compared with standard defibrillation in adult patients with refractory ventricular fibrillation during out-of-hospital cardiac arrest. Patients were treated with one of these three techniques according to the strategy that was randomly assigned to the paramedic service. The primary outcome was survival to hospital discharge. Secondary outcomes included termination of ventricular fibrillation, return of spontaneous circulation, and a good neurologic outcome, defined as a modified Rankin scale score of 2 or lower (indicating no symptoms to slight disability) at hospital discharge.ResultsA total of 405 patients were enrolled before the data and safety monitoring board stopped the trial because of the coronavirus disease 2019 pandemic. A total of 136 patients (33.6%) were assigned to receive standard defibrillation, 144 (35.6%) to receive VC defibrillation, and 125 (30.9%) to receive DSED. Survival to hospital discharge was more common in the DSED group than in the standard group (30.4% vs. 13.3%; relative risk, 2.21; 95% confidence interval [CI], 1.33 to 3.67) and more common in the VC group than in the standard group (21.7% vs. 13.3%; relative risk, 1.71; 95% CI, 1.01 to 2.88). DSED but not VC defibrillation was associated with a higher percentage of patients having a good neurologic outcome than standard defibrillation (relative risk, 2.21 [95% CI, 1.26 to 3.88] and 1.48 [95% CI, 0.81 to 2.71], respectively).ConclusionsAmong patients with refractory ventricular fibrillation, survival to hospital discharge occurred more frequently among those who received DSED or VC defibrillation than among those who received standard defibrillation. (Funded by the Heart and Stroke Foundation of Canada; DOSE VF ClinicalTrials.gov number, .)