Advancing Veterinary CPR: Key Updates From the 2024 RECOVER Guidelines

Cardiopulmonary resuscitation (CPR) remains the essential intervention for dogs and cats experiencing cardiopulmonary arrest (CPA), offering the only viable method to achieve return of spontaneous circulation (ROSC) in these serious cases. The Reassessment Campaign on Veterinary Resuscitation (RECOVER) guidelines have given veterinary professionals confidence in providing evidence-supported CPR practices over the past decade. Updated reported survival-to-discharge rates range from 5% to 7% in dogs and 1% to 19% in cats.^1-4 For patients suffering from acute, reversible causes of CPA, such as anesthetic complications, outcomes can be significantly higher, especially with timely and effective resuscitation efforts.

The 2012 RECOVER CPR guidelines, the first evidence-based framework for veterinary resuscitation, established a global standard for CPR in dogs and cats. Over the past decade, the RECOVER initiative has trained tens of thousands of veterinary professionals, transforming CPR practices worldwide. These guidelines have not only reshaped clinical protocols but also highlighted the importance of adherence to evidence-based recommendations for better outcomes.

In 2024, the RECOVER initiative published updated CPR guidelines, reflecting advancements in veterinary and human medical research. These updates refine the approaches to basic life support (BLS),² advanced life support (ALS),³ and monitoring,⁴ introducing significant revisions aimed at improving outcomes in veterinary CPR (BOX 1). This article highlights the key updates to the RECOVER CPR algorithm, offering insights into the latest recommendations and their practical application in clinical settings. Whether addressing shockable rhythms, optimizing chest compression techniques, or refining drug protocols, these updates mark a significant step forward in veterinary resuscitation science.

CPR Overview

This section will briefly overview the RECOVER CPR guidelines and how they practically come together through the CPR algorithm for dogs and cats (FIGURE 1). The general approach and flow to CPR remains similar to that outlined in the 2012 RECOVER guidelines, which can be read in more detail at go.navc.com/4gNy8ty. CPR can be broken into 3 key elements: initiating BLS, initiating ALS, and following CPR workflow.

Figure 1. The CPR algorithm for dogs and cats provides a logical workflow of the RECOVER CPR process. It is concisely organized for use during CPR to practically employ evidence-based guidelines. Courtesy © RECOVER
ALS = advanced life support; BLS = basic life support; CPR = cardiopulmonary resuscitation; ECG = electrocardiogram; ETCo2 = end-tidal carbon dioxide PCA = post–cardiac arrest; PEA = pulseless electrical activity; RECOVER = Reassessment Campaign on Veterinary Resuscitation; ROSC = return of spontaneous circulation; VF = ventricular fibrillation; VT = ventricular tachycardia

Initiating Basic Life Support

BLS is designed to sustain the cardiorespiratory system in, apneic dogs and cats through external chest compressions and positive pressure ventilation. Unless a “do not resuscitate” order is in place, BLS should be initiated immediately. The techniques used depend on patient size, anatomy, and the resources and personnel available. Effective BLS requires a structured and prompt response to maximize the chances of achieving ROSC and survival.²

When a patient is found collapsed, the rescuer should first call for help and then evaluate the patient’s responsiveness to tactile and auditory stimuli by employing the shake and shout method (FIGURE 2). If the patient is found to be unresponsive and you are alone, employ single-rescuer BLS by quickly assessing the airway for obstructions, ensuring no more than a 10- to 15-second delay before starting chest compressions. Chest compressions should be performed at a compression-to-ventilation ratio of 30:2, delivering 30 compressions followed by 2 breaths using a tight-fitting facemask or, if unavailable, mouth-to-nose rescue breaths. If rescue breaths pose a zoonotic or chemical risk to the rescuer, chest compression–only CPR is recommended. Proper head and neck alignment during ventilation prevents airway obstruction.²

Figure 2. The CPR initial assessment algorithm provides the logical flow in assessing an unresponsive patient leading into BLS. Courtesy © RECOVER
BLS = basic life support; CPR = cardiopulmonary resuscitation

In multirescuer settings, one rescuer should begin compressions immediately while another addresses the airway. If an obstruction is identified, it should be removed and the trachea intubated, or alternative airway methods like tracheostomy should be used. Ventilation should start at a rate of 10 breaths/min (1 breath every 6 seconds), with each inspiration lasting 1 second. Proper ventilation can be achieved using a manual resuscitation bag or an anesthesia machine, while ensuring that the appropriate equipment size and settings are used to prevent lung overinflation or barotrauma. For manual resuscitation bags, the pop-off valve (typically rated at 40 to 60 cm H₂O) should be present and functional. For anesthesia circuits, maintaining a peak airway pressure of 30 to 40 cm H₂O during compressions is essential, reducing it to less than 20 cm H₂O during the pause for rhythm assessment in between compression cycles.¹ The rescuer should confirm intubation visually if possible, secure the tube in place, and inflate the cuff to ensure effective positive pressure ventilation. Multirescuer BLS employs simultaneous compressions and positive pressure ventilation in 2-minute cycles to optimize oxygen delivery and circulation.²

Chest compressions in BLS vary based on the patient’s size and chest shape. Round-chested and narrow-chested animals should be positioned in lateral recumbency, whereas wide-chested animals may be placed in dorsal recumbency. The rescuer’s hand placement is tailored to the anatomy, with techniques like overlapping hands for larger dogs or circumferential compression for small dogs and cats. Compressions should be performed at a rate of 100 to 120/min to a depth of one-third to one-half of the thorax if in lateral recumbency and to a depth of one-quarter of the thorax in dorsal recumbency, ensuring full recoil between compressions. BLS is conducted in uninterrupted 2-minute compression cycles, with compressors switching roles to prevent fatigue. Transition times between cycles should be less than 10 seconds, as minimizing interruptions is critical for maintaining blood flow, achieving ROSC, and improving patient outcomes.²

Initiating Advanced Life Support

Initiating ALS begins with monitoring the patient using an electrocardiogram (ECG) and capnometry. Vascular access is established next, with intravenous access preferred; if unavailable within 2 minutes, intraosseous catheterization should be pursued while continuing intravenous attempts. In cases where vascular access is unattainable, intratracheal drug administration is a less desirable option. Any applicable reversal agents are recommended to be administered once venous access is established to address any cardiovascular or respiratory depression.³

Capnometry is a critical ALS tool that serves multiple purposes during CPR. It confirms endotracheal tube placement, with consistent carbon dioxide waveforms indicating correct placement. An end-tidal carbon dioxide (ETco₂) value of ≥ 12 mm Hg generally supports proper intubation, while a very low ETco₂ value (< 5 mm Hg) may signal issues requiring verification by other methods (e.g., direct visualization). Most important, capnography provides continuous feedback on chest compression quality, with an ETco₂ target of ≥ 18 mm Hg indicating effective circulation. Keeping the ETco₂ above 18 mm Hg, and as high as possible, is thought to be the most impactful factor to achieving ROSC and positive neurologic outcome.³

Treatment pathways in ALS are determined by the ECG rhythm identified during the “pause and check” following each 2-minute compression cycle (FIGURES 1 AND 3). For patients with nonshockable rhythms, such as asystole or pulseless electrical activity (PEA), CPR continues with vasopressors like epinephrine (0.01 mg/kg) or vasopressin (0.8 U/kg) administered every 3 to 5 minutes (every other cycle) (FIGURE 4). If high vagal tone is suspected, a single dose of atropine (0.04 to 0.054 mg/kg) may be given early in the resuscitation effort. For shockable rhythms, such as ventricular fibrillation (VF) or pulseless ventricular tachycardia (VT), defibrillation is the priority, using a biphasic defibrillator at 2 J/kg (4 J/kg for monophasic). Both pathways prioritize minimizing interruptions to compressions and adherence to evidence-based ALS recommendations to maximize the chances of ROSC.³

Figure 3. The CPR ECG algorithm provides a simple and standard method to diagnosing ECG rhythms during the intercycle patient assessment. Courtesy © RECOVER
CPR = cardiopulmonary resuscitation; ECG = electrocardiogram; PEA = pulseless electrical activity; ROSC = return of spontaneous circulation; VF = ventricular fibrillation; VT = ventricular tachycardia

Figure 4. The cardiopulmonary resuscitation (CPR) dosing chart for dogs and cats serves as a cognitive aid, eliminating the need to calculate drug doses and defibrillation energy settings during CPR. Courtesy © RECOVER

Following CPR Flow

Once CPR is initiated, the process follows a structured flow: perform 2-minute cycles of high-quality BLS, pause briefly to perform a pulse check and assess for ROSC, and resume chest compressions while delivering treatments based on whether the rhythm is shockable or nonshockable (FIGURE 3). Prompt defibrillation should be delivered in patients with shockable rhythms, with refractory cases (from the second time around) requiring doubled defibrillation doses and potentially additional therapies, including vasopressors (epinephrine or vasopressin), antiarrhythmics (lidocaine or amiodarone), or β-blockers (esmolol) to mitigate catecholamine-driven arrhythmias. For nonshockable rhythms, vasopressors remain the focus, with atropine considered in cases of suspected high vagal tone. This cycle repeats systematically, ensuring minimal interruptions to compressions, while the team works to optimize circulation and oxygen delivery. In prolonged cases of CPR exceeding 15 minutes, sodium bicarbonate therapy may be considered if severe acidosis is present (pH < 7).

Decisions about discontinuing CPR follow precise criteria. If the team identifies a palpable femoral pulse during the 10-second “pause and check” or observes a sudden and sustained rise in ETco₂ (e.g., by ≥ 10 mm Hg to a level ≥ 35 mm Hg) coupled with an arterial pulse distinct from compressions, ROSC is confirmed, and resuscitation efforts should shift to post–cardiac arrest care. If neither ROSC nor signs of improvement occur despite exhaustive efforts, the team may decide to cease resuscitation based on the patient’s condition and prognosis.

High-quality BLS combined with ALS interventions are essential to restoring spontaneous circulation, regardless of the arrest’s cause. The updated 2024 RECOVER CPR algorithm for dogs and cats provides a comprehensive framework to navigate these complex scenarios, offering step-by-step guidance for initiating, managing, and concluding resuscitation efforts (FIGURE 1). Teams are encouraged to familiarize themselves with the full guidelines, available at recoverinitiative.org, to refine their clinical decision-making and optimize outcomes.

Key Updates in the 2024 Guidelines

Chest Compressions in Wide-Chested Animals

The new guidelines include adjustments to performing chest compressions in wide-chested animals (those with chests that are wider than they are deep), addressing both compression depth and positioning to enhance the effectiveness of blood flow generation during CPR. Effective BLS remains the foundation of resuscitation because it directly drives blood flow. Without proper execution, the success of subsequent interventions falters. While fundamental principles like compression rate (100 to 120/min) and allowing full chest recoil remain unchanged, significant updates have been made for animals with wide chests.

For wide-chested animals positioned in dorsal recumbency, the recommended compression depth has been revised to approximately 25% of the anterior-to-posterior chest diameter, rather than the standard one-third to one-half used for other body types. This adjustment is based on the fact that in these animals, a significant proportion of the posterior chest is occupied by noncompressible structures like the spine, epaxial muscles, and surrounding tissues. Compressing only 25% of the chest’s anterior-to-posterior distance achieves the desired reduction in the compressible portion of the thoracic cavity, ensuring adequate circulation while minimizing the risk of overcompression and associated harm (FIGURE 5).

Figure 5A. Diagram of the cross-section of the thorax of a wide-chested animal in dorsal recumbency in a fully recoiled state. Illustration: Kip Carter

Figure 5B. Diagram of the cross-section of the thorax of a wide-chested animal in dorsal recumbency compressed to 25% depth. Note the ventricles are already adequately compressed to eject blood out of the heart and are already being pressed against the tissues between it and around the spine. Illustration: Kip Carter

Figure 5C. Diagram of the same view with compressions at 50% depth. Note that there is little to no gain in ejecting the blood out of the ventricles, and the heart and tissues between it and the spine are sustaining excessive pressure and damage. Illustration: Kip Carter

Recumbency During Intubation for Wide-Chested Animals

Another key update addresses the challenges of intubating wide-chested animals, particularly brachycephalic breeds with excess soft tissue. The guidelines now recommend starting chest compressions in lateral recumbency until intubation is completed, as intubation is vital for effective ventilation and oxygenation. Once the airway is secured, the animal can be repositioned to dorsal recumbency for compressions. To minimize interruptions in the transition, the guidelines recommend making the move to dorsal recumbency during the pause in between compression cycles. If dorsal positioning proves unstable or ineffective in generating sufficient ETco₂, lateral compressions may be continued. These modifications provide a practical approach to maximizing CPR effectiveness in wide-chested animals while addressing anatomic and procedural challenges. Dorsal recumbency endotracheal intubation is reasonable if veterinary professionals have experience with it and can minimize the time required for intubation.

Compression Techniques for Small Dogs and Cats

There are now 3 distinct chest compression techniques described specifically for small dogs and cats, aiming to optimize blood flow while minimizing the risk of overcompression and thoracic injury. These techniques prioritize targeting the heart’s ventricles, as compressing over the heart base can obstruct blood flow and significantly reduce circulation effectiveness. The revised approaches emphasize precision and adaptability based on a patient’s size and anatomy.

1. Circumferential (2-thumb) technique: This method involves encircling the chest with both hands, placing the thumbs on one side of the chest and the fingers on the other. Compressions are applied with the thumbs over the heart, compressing the ventricles between the thumbs and the opposing fingers. This technique combines elements of the thoracic and cardiac pump mechanisms and is particularly effective for stabilizing small patients while ensuring targeted compression over the ventricles (FIGURE 6A).

Figure 6A. Circumferential (2-thumb) technique: This technique involves encircling the chest with both hands and compressing the ventricles between the thumbs and opposing fingers for effective and targeted compression in small patients. Courtesy Atsuko Yagi

2. One-Handed Technique: In this approach, the dominant hand wraps around the chest, with the thumb placed on one side and the opposing fingers on the other, directly compressing the ventricles from the bottom toward the atria to effectively eject blood out of the heart. The nondominant hand is used to stabilize the patient’s back. This technique provides precise control and reduces the risk of overcompression, making it an excellent option for adult cats and small dogs (FIGURE 6B).

Figure 6B. One-handed technique: The dominant hand compresses the ventricles by wrapping around the chest, while the nondominant hand stabilizes the back, providing precision and reducing the risk of overcompression in adult cats and small dogs. Courtesy Atsuko Yagi

3. Heel of the hand technique: This method uses the heel of 1 hand to apply compressions directly over the ventricles. It is crucial to ensure that pressure is focused on the ventricle region and not the heart base, as compressing the base can restrict blood flow out of the heart. Adjusting hand placement closer to the sternum, if needed, can significantly improve outcomes by enhancing blood flow and increasing ETco₂ levels. This technique may be required for small dogs of intermediate size with stiff enough chests that the 1-handed technique is not sustainable (FIGURE 6C).

Figure 6C. Heel of the hand technique: This approach uses the heel of 1 hand to apply compressions over the ventricles, avoiding the heart base, with adjustments closer to the sternum improving blood flow and cardiopulmonary resuscitation outcomes for intermediate-sized small dogs. Courtesy Atsuko Yagi

These techniques replace the traditional 2-handed compression method used for larger patients, which is no longer recommended for small dogs and cats due to the high risk of overcompression and injury. The guidelines encourage the use of ETco₂ monitoring to assess the effectiveness of compressions, ensuring blood flow is optimized throughout resuscitation efforts.

Nonintubated Ventilation

The updated RECOVER CPR guidelines emphasize the continued importance of ventilation during resuscitation, whether or not the patient is intubated. Intubation remains the gold standard for ventilation because ventilation can be delivered while chest compressions are being performed when there is a sealed airway. However, new recommendations address scenarios where intubation is not immediately possible, offering practical solutions for nonintubated animals while prioritizing rescuer safety.

For nonintubated animals, ventilation is recommended over chest compression–only CPR. The preferred approach involves using a tight-fitting mask with a resuscitator bag, allowing for oxygen supplementation and reducing risks to the rescuer. This method effectively achieves respiratory targets for carbon dioxide and oxygen while maintaining safety. In cases where intubation equipment is unavailable, the guidelines suggest performing mouth-to-nose ventilation if there is no perceived risk to the rescuer, such as exposure to zoonotic diseases or hazardous substances. If risks are present, chest compression–only CPR is acceptable as a temporary measure until equipment or intubation becomes available.

Recognizing the challenges in delivering effective ventilation for certain patient anatomies, such as brachycephalic breeds or newborn animals, ongoing efforts are focused on developing better equipment. Innovations include creating smaller masks and resuscitator bags tailored to newborns and masks designed to accommodate the wide variety of facial shapes encountered in veterinary medicine. For brachycephalic animals, techniques to occlude the gastrointestinal pathway during ventilation are being explored to prevent air from entering the stomach. These updates aim to enhance ventilation practices while prioritizing both patient outcomes and rescuer safety in diverse clinical scenarios.

Increased ETco₂ Targets in CPR

The 2024 RECOVER guidelines raise the target for ETco₂ levels during CPR from 15 mm Hg to 18 mm Hg, reflecting new evidence that higher ETco₂ values correlate with improved outcomes.^1,4-6 ETco₂ serves as a critical indicator of blood flow generated by chest compressions, with higher values indicating better circulation, oxygen delivery, and cellular energy production.^4-6 This measure has long been used to assess the quality of CPR efforts, as sufficient blood flow is essential not only for achieving ROSC but also for optimizing neurologic recovery and overall survival.

Previous guidelines set the ETco₂ target at 15 mm Hg based on limited data from a single-center study, which indicated that dogs below this threshold were less likely to achieve ROSC.^7,8 However, newer observational studies suggest that higher ETco₂ values, closer to 18 mm Hg or above, are more effective discriminators for successful outcomes without associated harm.^1,4-6 These findings led to the adjustment in the current guidelines, reinforcing the goal of maximizing circulation and oxygen delivery to vital organs during CPR. Although specific ETco₂ targets vary by species (cats may achieve mid-20s and dogs closer to 20 mm Hg), the overarching principle remains to aim for the highest achievable ETco₂ for each patient (FIGURE 7).

Figure 7. Aiming for end-tidal carbon dioxide values as high as possible beyond the target 18 mm Hg is likely to improve chances of successful outcomes.

Importantly, this update emphasizes that ETco₂ targets should not be viewed as rigid thresholds but rather as benchmarks for optimizing CPR quality. Rescuers should continuously strive to improve chest compressions and ventilate appropriately in all situations to raise ETco₂ levels as high as possible for the patient. Higher ETco₂ values are linked not only to better chances of ROSC but also to improved postresuscitation outcomes,^4,9,10 emphasizing their significance in guiding effective resuscitation efforts.

High-Dose Epinephrine Removed From Guidelines

The updated RECOVER guidelines have removed high-dose epinephrine (HDE) as a recommendation for resuscitation efforts, simplifying the dosing protocol to a single standard dose of epinephrine. The decision reflects growing concerns about the potential risks associated with HDE and its lack of evidence for improving meaningful outcomes in veterinary patients. While HDE was historically thought to increase the likelihood of ROSC, studies have observed that fewer patients survive to discharge on HDE when compared to a standard dose, with one of the causes being HDE constricting coronary and cerebral vasculature to the point of compromising blood flow to them and other vital organs.^3,11-14 This could negatively affect neurologic outcomes, which are crucial for postresuscitation quality of life.

In reviewing the available evidence, the RECOVER team found no data supporting improved neurologic outcomes in dogs and cats with HDE use. Additionally, human studies and pediatric research raised concerns about potential harm, including poorer long-term functional recovery.^3,12-14 Even ROSC rates were inconsistent, with studies showing mixed results: some indicating a benefit, others showing no effect, and a few suggesting harm.^12,13,15,16 Given this variability and the absence of high-quality evidence for improved survival or postresuscitation quality of life in veterinary species, HDE was deemed unnecessary and potentially detrimental.

The removal of HDE also aligns with the goal of simplifying CPR protocols. Standardizing epinephrine to a single dose reduces the cognitive load during high-stress resuscitation events, allowing teams to focus on high-quality chest compressions and other life-saving measures. This streamlining of the guidelines ensures that resuscitation efforts remain straightforward and effective while prioritizing outcomes that matter most, such as survival with good neurologic function. Standard-dose epinephrine continues to be recommended as part of the protocol for nonshockable rhythms like asystole and PEA.

Give Atropine Once, As Soon As Determined to Be Needed

The 2024 RECOVER guidelines update the recommendations for atropine use during CPR, emphasizing its role in specific scenarios and highlighting the importance of precise dosing. Atropine (0.04 mg/kg IV or IO) is now recommended as a single dose during CPR for dogs and cats with nonshockable arrest rhythms and should be administered as early as possible after the rhythm diagnosis. This targeted approach aims to address cases where high vagal tone is suspected to have contributed to cardiac arrest, making atropine particularly effective in reversing bradycardia-induced hemodynamic compromise.

The recommendation against repeated doses of atropine is based on concerns about its pharmacokinetics and potential for harm. Atropine has a relatively long half-life, remaining active for approximately 30 minutes in dogs at the standard dose and up to 4 hours in humans.² Repeated doses risk accumulation, which could mimic the effects of higher doses that have been associated with worse outcomes, including detrimental effects on myocardial oxygen consumption during the post–cardiac arrest period. Additionally, higher doses have shown evidence of harm in experimental studies,^3,17 reinforcing the importance of avoiding repeated administration.

The use of atropine is justified by its potential benefit in cases where parasympathetic (vagal) tone is a contributing factor. These situations include gastrointestinal diseases resulting in vomiting and diarrhea, respiratory disease involving coughing, ophthalmologic surgery, laryngeal manipulation (intubation), and opioid administration. Experimental data from dogs suggest some benefit,^3,18,19 while studies in humans and other species have shown mixed results.^3,17,19,20 Despite these uncertainties, the committee deemed it reasonable to retain atropine in the guidelines due to the minimal risk associated with a single standard dose and its potential for benefit in cardiac arrest in cases of bradycardia.

The emphasis on early administration reflects the physiologic rationale that atropine is most effective when given promptly in cases of vagal-mediated arrest. Waiting to administer atropine later in the resuscitation process, or after other interventions have failed, diminishes its potential to address the underlying cause of arrest. Simplifying the protocol to a single, early dose of atropine reduces cognitive load for the resuscitation team and aligns with the broader goal of optimizing CPR efficiency and effectiveness.

Changes to Treating Refractory Shockable Rhythms

Guidelines on the treatments for refractory shockable rhythms have been refined to improve clarity, efficiency, and outcomes. A refractory shockable rhythm is now clearly defined as a rhythm that persists after a first defibrillation attempt and remains shockable at the subsequent rhythm check. This streamlined definition replaces previous ambiguous criteria, enabling more consistent clinical application.

Adjustments to Defibrillation Protocols

For shockable rhythms such as VF or pulseless VT, the first defibrillation should be administered at the standard dose of 2 J/kg using a biphasic defibrillator. If unsuccessful, the second defibrillation dose, applied a compression cycle after the first shock, should be doubled to 4 J/kg. This dose escalation is applied only once; all subsequent shocks should remain at 4 J/kg. The adjustment reflects evidence from human clinical trials and experimental studies in animals that suggests an energy escalation strategy improves outcomes.^3,21-25 The RECOVER guidelines recommend doubling the defibrillation dose as a sufficient level of increase for improved outcomes while avoiding the unknown risks of even higher doses. Additional dose escalation beyond 4 J/kg is not recommended due to the lack of evidence regarding safety and efficacy at higher doses.

Vasopressors

Vasopressors play a crucial role in managing refractory shockable rhythms. In this case, vasopressin (0.8 U/kg IV or IO) is now the preferred first-line vasopressor, with epinephrine (0.01 mg/kg IV or IO) recommended only if vasopressin is unavailable. Administration of epinephrine in shockable rhythms before it is considered refractory is not advised due to its association with poorer neurologic outcomes and survival rates. The targeted vasoconstrictive effects of vasopressin improve coronary perfusion pressure without the β₁-mediated proarrhythmogenic effects of epinephrine.

Antiarrhythmics

For antiarrhythmic therapy, lidocaine (2 mg/kg IV or IO) is recommended for dogs with refractory pulseless VT or VF after the initial shock, based on evidence suggesting its potential to improve rates of ROSC.^3,8 However, the guidelines do not recommend the use of lidocaine in cats due to their increased sensitivity to its cardiovascular and central nervous system effects, making amiodarone the preferred antiarrhythmic. For dogs, amiodarone (5 mg/kg IV) can be used as an alternative if lidocaine is unavailable. Caution is advised with amiodarone formulations containing polysorbate 80 due to documented hemodynamic side effects in dogs.²⁶ Aqueous formulations of amiodarone are considered safer but require large infusion volumes, making them less practical during CPR.

β-Blockers

A notable addition to the 2024 guidelines is the recommendation for esmolol (0.5 mg/kg IV or IO over 3 to 5 minutes, followed by a continuous infusion of 50 µg/kg/min) in cases where shockable rhythms persist after the first defibrillation. Esmolol, a β₁-selective antagonist, mitigates the harmful effects of excessive catecholamine stimulation, which is common in shockable rhythms following epinephrine administration. Although evidence is limited, experimental studies in animals suggest that esmolol can improve ROSC rates and reduce myocardial oxygen demand.^3,27-35 The β₁-specific nature of esmolol minimizes the risk of bronchoconstriction associated with nonselective β-blockers like propranolol.

Practical Implications

These updates simplify the treatment of refractory shockable rhythms by providing clear definitions, refined dosing strategies, and targeted pharmacologic interventions. By emphasizing precision and minimizing potential harm, these changes aim to improve both the immediate and long-term outcomes for veterinary patients undergoing CPR for shockable arrest rhythms.

The RECOVER Initiative

The updated RECOVER guidelines represent a vital step forward in the advancement of veterinary CPR, emphasizing the importance of evidence-based practices in improving outcomes for dogs and cats experiencing CPA. These guidelines, rooted in the latest research, provide clear, actionable recommendations to refine resuscitation efforts and address challenges encountered in clinical settings. By prioritizing high-quality BLS as the foundation and incorporating targeted ALS strategies, the updates ensure a balanced and effective approach to CPR.

The RECOVER certification program trains veterinary professionals globally, equipping them with the competence to confidently deliver high-standard CPR, and fosters a connected community committed to improving care quality. Supported by initiatives like the global CPR registry, which analyzes real-world data to refine guidelines, RECOVER bridges knowledge gaps and enhances the science of resuscitation. Together, the guidelines, certification programs, and research efforts provide a comprehensive framework for veterinary teams to deliver lifesaving care and improve patient outcomes.

A common question often asked about investing efforts in CPR education and training is, “Is it worth it? The chances of success are so low.” The correct perspective instead is that because some patients with reversible causes of CPA can go on to live meaningful lives, it is our responsibility to be competent in delivering high-quality CPR to give them the best chance at survival. We will not save every patient, but every patient we save and send home to their family means the world to them. In a way, by honing our CPR skills to improve ROSC and survival rates, we are truly saving worlds.

Disclosure

Kenichiro Yagi is the program director for the RECOVER Initiative.