Use of Double Sequential External Defibrillation in the United States Before and After the DOSE VF Randomized Clinical Trial.

OBJECTIVES

The Double Sequential External Defibrillation for Refractory Ventricular Fibrillation (DOSE VF) trial demonstrated improved outcomes for patients randomized to double sequential external defibrillation (DSED) in comparison to standard defibrillation, yet large-scale data on prehospital DSED use remain limited. We evaluated prehospital DSED use before and after publication of DOSE VF.

METHODS

We conducted a retrospective analysis of adult (>18 years of age) non-traumatic out-of-hospital cardiac arrest (OHCA) patients who had an initial rhythm of ventricular fibrillation or pulseless ventricular tachycardia and at least 4 successive defibrillation attempts in the ESO Data Collaborative from 2018-2024. We excluded patients with return of spontaneous circulation prior to the fourth defibrillation, resuscitation-limiting advanced directives, or OHCA due to drowning or overdose. To minimize the influence of agencies joining the Collaborative during the study period, we excluded agencies that did not contribute data during the first study year. We identified DSED using three methods: 1.) documentation of "Dual Sequence Defibrillation (DSD)", 2.) defibrillation at a 400 J or 720 J energy setting, or 3.) two defibrillations within 5 s. The DOSE VF trial was published in November 2022, and Q4 2022 was used as a washout period. We classified patients as treated pre-DOSE VF if treated before Q4 2022, and post-DOSE VF if treated after Q4 2022. We compared pre- and post-DOSE VF use of DSED using Pearson's 𝜒2 test and an interrupted time-series analysis using segmented Poisson regression with 3-month non-overlapping segments.

RESULTS

We identified 16,450 DSED-eligible patients treated by 906 emergency medical services agencies. Estimates of DSED use varied by ascertainment method (Method 1: 3.7%, Method 2: 1.8%, Method 3: 4.4%, any method: 7.6%). The use of DSED detected by any method increased post-DOSE VF (pre vs. post: 822/11,228 (7.3%) vs. 381/4,625 (8.2%), p = 0.048). Segmented Poisson regression suggested an increase in the rate of DSED use (slope change) after DOSE VF (RR: 1.09 (1.04, 1.14) per quarter).

CONCLUSIONS

Our findings suggest an increasing rate of DSED use after publication of DOSE VF, but the proportion of eligible patients receiving DSED remains low. Limitations include the potential for patient misclassification by our DSED ascertainment methods.