PICO Question : For infants and children with shock-refractory ventricular fibrillation (VF) or pulseless
ventricular tachycardia (pVT) (P), does amiodarone (I), when compared to lidocaine (C), improve survival
at hospital discharge, return of spontaneous circulation (ROSC), termination of arrhythmia, recurrence
of VF or risk of complications (O).
Introduction
We identified 3 relevant articles in the literature addressing the above issue. One was in pediatrics and
was an observational retrospective cohort study with patients in VF or pVT who received lidocaine,
amiodarone or both. The relevant outcomes studied in this paper were ROSC and survival to hospital
discharge. The other two were RCTs in adults. One was incessant, but pulsatile, VT and the other was
ventricular fibrillation in adults. The outcomes studied in these papers were termination of arrhythmia,
and survival to discharge, respectively.
Quality of Evidence
We found no randomized studies in pediatrics and two randomized studies in adults in comparison of
amiodarone and lidocaine in the setting of pulseless VT or VF.
For the critical outcome of survival to discharge, we found one randomized controlled trial in adults and
one observational cohort study in pediatrics, both of very low quality. The observational study with no
control group and a sample size less than 400, showed 21.6% (37/171) survival to discharge in
amiodarone group and 25.8% (76/295) in the lidocaine group. The randomized controlled trial was in
adult population and had a sample size less than 400. Survival to discharge was seen in 22.8% (41/180)
in the amiodarone group and 12.0% (20/167) in the lidocaine group.
For the important outcome of ROSC, the pediatric observational study demonstrated 50.9% (87/171)
ROSC in the amiodarone group and 62.4%(184/295) in the lidocaine group. (OR 2.02, 1.36-3.03). This
observational study was of very low quality, as there was no control group and a small sample size.
For the important outcome of termination of arrhythmia, one randomized controlled study in adults of
very low quality studied this outcome. The study was in adults, had a small sample size and had low
patient enrollment. They showed 48.3% (14/29) termination on arrhythmia in the amiodarone group
and 10.3% (3/29) in the lidocaine group.
Gap analysis
The major limitation in this analysis is the lack of RCTs of good quality in pediatrics, comparing
amiodarone and lidocaine directly in the setting of pVT or VF. All of the representative data from the
papers included is of low quality. The pediatric study is an observational study that found lidocaine to
be superior to amiodarone. However, in the very low quality RCTs, although in adults, amiodarone was
found to be superior to lidocaine. Given the very low quality of the data available, and the discrepancy
of potentially superior agent between studies, no recommendation can be made between these drugs.
Treatment Recommendations
The confidence in effect estimates is so low that the panel feels a recommendation to change current
practice is too speculative. We suggest that either amiodarone or lidocaine can be used in the setting of
pVT/VF in infants and children.
References
1. Valdes, SO, Donoghue, AJ, Hoyme, DB, Hammond, R, Berg, MD, Berg, RA, and Samson, RA. Outcomes
associated with amiodarone and lidocaine in the treatment of in-hospital pediatric cardiac arrest with
pulseless ventricular tachycardia or ventricular fibrillation. Resuscitation 2014;85:381-386.
2. Somberg, JC, Bailin, SJ, Haffajee, CI, Paladino, WP, Kerin, NZ, Bridges, D, Timar, S, Molar, J, and the
Amio-Aqueous Investigators. Intravenous lidocaine versus intravenous amiodarone in a new aqueous
formulation for incessant ventricular tachycardia. Am J Cardiol 2002; 90:853-859.
3. Dorian, P, Cass, D, Schwartz, B, Cooper, R, Gelaznikas, R, and Barr, A. Amiodarone as compared with
lidocaine for shock-resistant ventricular fibrillation. NEJM 2002; 346(12): 884-890.