{"id":127557,"date":"2025-03-11T18:34:24","date_gmt":"2025-03-11T18:34:24","guid":{"rendered":"https:\/\/todaysveterinarynurse.com\/?p=127557"},"modified":"2025-03-11T19:07:41","modified_gmt":"2025-03-11T19:07:41","slug":"updates-from-the-2024-recover-guidelines","status":"publish","type":"post","link":"https:\/\/navc.sitepreview.app\/todaysveterinarynurse.com\/emergency-medicine-critical-care\/updates-from-the-2024-recover-guidelines\/","title":{"rendered":"Advancing Veterinary CPR: Key Updates From the 2024 RECOVER Guidelines"},"content":{"rendered":"<div class=\"su-spacer\" style=\"height:20px\"><\/div><div class=\"su-note\"  style=\"border-color:#d8d8d8;border-radius:3px;-moz-border-radius:3px;-webkit-border-radius:3px;\"><div class=\"su-note-inner su-u-clearfix su-u-trim\" style=\"background-color:#f2f2f2;border-color:#ffffff;color:#333333;border-radius:3px;-moz-border-radius:3px;-webkit-border-radius:3px;\"><b>Abstract<\/b><\/p>\n<p class=\"p1\">The 2024 RECOVER (Reassessment Campaign on Veterinary Resuscitation) cardiopulmonary resuscitation (CPR) guidelines represent a significant milestone in advancing veterinary resuscitation practices. Building on the foundation established by the 2012 guidelines, the updates incorporate the latest research and evidence-based recommendations to optimize outcomes for dogs and cats experiencing cardiopulmonary arrest. By emphasizing high-quality basic life support and targeted advanced life support, the guidelines provide a comprehensive framework to improve survival rates and patient outcomes. This article summarizes these updates, offering practical insights to help veterinary professionals deliver effective and life-saving CPR.<\/p>\n<p><b>Take-Home Points <\/b><\/p>\n<ul>\n<li class=\"p1\"><b>Tailored compression techniques:<\/b> Specific methods for chest compressions in small animals and wide-chested breeds enhance circulation while reducing injury risk.<\/li>\n<li class=\"p1\"><b>End-tidal carbon dioxide (ETco<sub>2<\/sub>) target increase:<\/b> Raising the target ETco<sub>2<\/sub> from 15 mm Hg to 18 mm Hg during CPR improves blood flow and neurologic outcomes.<\/li>\n<li class=\"p1\"><b>Pharmacologic updates:<\/b> High-dose epinephrine has been removed due to potential risks, while vasopressin is now prioritized for shockable rhythms.<\/li>\n<li class=\"p1\"><b>Nonintubated ventilation:<\/b> Tight-fitting masks or mouth-to-nose ventilation are recommended alternatives when intubation is not feasible.<\/li>\n<li class=\"p1\"><b>Revised defibrillation protocols:<\/b> Second defibrillation doses are doubled to 4 J\/kg, with subsequent shocks maintaining this dose.<\/li>\n<li class=\"p1\"><b>Atropine use:<\/b> A single dose of atropine early in CPR is recommended when high vagal tone is suspected, avoiding repeated doses.<\/li>\n<li class=\"p1\"><b>\u03b2-Blockers for shockable rhythms:<\/b> Esmolol is introduced for refractory shockable rhythms to mitigate catecholamine effects.<\/li>\n<li class=\"p1\"><b>Emphasis on high-quality basic life support:<\/b> Sustained and uninterrupted compressions remain the cornerstone of effective resuscitation.<\/li>\n<li class=\"p1\"><b>Streamlined protocols:<\/b> Clear guidelines for refractory rhythms and drug dosing simplify decision-making during high-stress scenarios.<\/li>\n<li class=\"p1\"><b>Evidence-based updates:<\/b> The revisions reflect advancements in veterinary and human CPR research, prioritizing patient outcomes.<\/li>\n<\/ul>\n<\/div><\/div>\n<p class=\"p1\"><span class=\"s1\">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.<sup>1-4<\/sup> 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.<\/span><\/p>\n<p class=\"p1\"><span class=\"s1\">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.<\/span><\/p>\n<p class=\"p1\"><span class=\"s1\">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),<sup>2<\/sup> advanced life support (ALS),<sup>3<\/sup> and monitoring,<sup>4<\/sup> introducing significant revisions aimed at improving outcomes in veterinary CPR (<\/span><span class=\"s2\"><b>BOX 1<\/b><\/span><span class=\"s1\">). 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.<\/span><\/p>\n<div class=\"su-box su-box-style-default\" id=\"\" style=\"border-color:#606060;border-radius:3px;\"><div class=\"su-box-title\" style=\"background-color:#939393;color:#FFFFFF;border-top-left-radius:1px;border-top-right-radius:1px\">BOX 1 Summary of Key Updates in the 2024 RECOVER Guidelines<sup>1<\/sup><\/div><div class=\"su-box-content su-u-clearfix su-u-trim\" style=\"border-bottom-left-radius:1px;border-bottom-right-radius:1px\">\n<ul>\n<li><strong>Chest compressions in wide-chested animals<\/strong> Adjusts compression depth for wide-chested animals in dorsal recumbency to 25% of the anterior-to-posterior chest diameter to optimize circulation and minimize risk of overcompression<\/li>\n<li><strong>Recumbency during intubation for wide-chested animals<\/strong> Recommends starting compressions in lateral recumbency until intubation is secured, with a transition to dorsal recumbency during a pause in between compression cycles after intubation<\/li>\n<li><strong>Compression techniques for small dogs and cats<\/strong> Introduces 3 distinct compression techniques\u2014circumferential\/2-thumb, 1-handed, and heel of the hand\u2014tailored to small dogs and cats to enhance precision and minimize injury<\/li>\n<li><strong>Nonintubated ventilation<\/strong> Emphasizes the use of tight-fitting masks and resuscitator bags for nonintubated patients, with mouth-to-nose ventilation as a temporary alternative if no risks are posed to rescuers<\/li>\n<li><strong>Increased ETco2 targets<\/strong> Raises ETco2 targets from 15 mm Hg to 18 mm Hg during CPR, with the goal of maximizing blood flow, oxygen delivery, and neurologic outcomes<\/li>\n<li><strong>Removal of high-dose epinephrine<\/strong> Eliminates high-dose epinephrine due to the lack of evidence supporting improved outcomes and potential risks, streamlining protocols to a single standard dose<\/li>\n<li><strong>Single early dose of atropine<\/strong> Updates recommendations to administer a single dose of atropine (0.04 mg\/kg IV or IO) early during CPR when high vagal tone is suspected, avoiding repeated doses to minimize harm<\/li>\n<li><strong>Refined definition of refractory shockable rhythms<\/strong> Defines refractory shockable rhythms as those persisting after the first defibrillation attempt, clarifying treatment pathways<\/li>\n<li><strong>Adjusted defibrillation protocols<\/strong> Recommends doubling the defibrillation dose to 4 J\/kg for the second shock, maintaining this dose for subsequent shocks without further escalation<\/li>\n<li><strong>Vasopressor preferences<\/strong> Prioritizes vasopressin (0.8 U\/kg) as the first-line vasopressor for refractory shockable rhythms, with epinephrine as an alternative when vasopressin is unavailable<\/li>\n<li><strong>Antiarrhythmic and \u03b2-blocker recommendations<\/strong> Suggests lidocaine (2 mg\/kg) for dogs and amiodarone for cats with refractory shockable rhythms and esmolol (0.5 mg\/kg IV or IO) as an adjunct for unresponsive shockable cases, especially if epinephrine was given<\/li>\n<\/ul>\n<p><em>CPR\u2009=\u2009cardiopulmonary resuscitation; ETco2 = end-tidal carbon dioxide; RECOVER\u2009=\u2009Reassessment Campaign on Veterinary Resuscitation<\/em><\/div><\/div>\n<h2 class=\"p2\">CPR Overview<\/h2>\n<p class=\"p1\"><span class=\"s1\">This section will briefly overview the RECOVER CPR guidelines and how they practically come together through the CPR algorithm for dogs and cats (<\/span><span class=\"s2\"><b>FIGURE\u00a01<\/b><\/span><span class=\"s1\">). 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 <\/span><a href=\"http:\/\/go.navc.com\/4gNy8ty\" target=\"_blank\" rel=\"noopener\"><span class=\"s2\">go.navc.com\/4gNy8ty<\/span><\/a><span class=\"s1\">. CPR can be broken into 3 key elements: initiating BLS, initiating ALS, and following CPR workflow.<\/span><\/p>\n<div id=\"attachment_127562\" style=\"width: 1912px\" class=\"wp-caption aligncenter\"><a href=\"https:\/\/todaysveterinarynurse.com\/wp-content\/uploads\/sites\/3\/2025\/03\/Yagi_RECOVERUpdate_TVNSpring25_Fig1.jpg\"><img fetchpriority=\"high\" decoding=\"async\" aria-describedby=\"caption-attachment-127562\" class=\"size-full wp-image-127562\" src=\"https:\/\/todaysveterinarynurse.com\/wp-content\/uploads\/sites\/3\/2025\/03\/Yagi_RECOVERUpdate_TVNSpring25_Fig1.jpg\" alt=\"\" width=\"1902\" height=\"2510\" srcset=\"https:\/\/navc.sitepreview.app\/todaysveterinarynurse.com\/wp-content\/uploads\/sites\/3\/2025\/03\/Yagi_RECOVERUpdate_TVNSpring25_Fig1.jpg 1902w, https:\/\/navc.sitepreview.app\/todaysveterinarynurse.com\/wp-content\/uploads\/sites\/3\/2025\/03\/Yagi_RECOVERUpdate_TVNSpring25_Fig1-227x300.jpg 227w, https:\/\/navc.sitepreview.app\/todaysveterinarynurse.com\/wp-content\/uploads\/sites\/3\/2025\/03\/Yagi_RECOVERUpdate_TVNSpring25_Fig1-776x1024.jpg 776w, https:\/\/navc.sitepreview.app\/todaysveterinarynurse.com\/wp-content\/uploads\/sites\/3\/2025\/03\/Yagi_RECOVERUpdate_TVNSpring25_Fig1-768x1014.jpg 768w, https:\/\/navc.sitepreview.app\/todaysveterinarynurse.com\/wp-content\/uploads\/sites\/3\/2025\/03\/Yagi_RECOVERUpdate_TVNSpring25_Fig1-1164x1536.jpg 1164w, https:\/\/navc.sitepreview.app\/todaysveterinarynurse.com\/wp-content\/uploads\/sites\/3\/2025\/03\/Yagi_RECOVERUpdate_TVNSpring25_Fig1-1552x2048.jpg 1552w\" sizes=\"(max-width: 1902px) 100vw, 1902px\" \/><\/a><p id=\"caption-attachment-127562\" class=\"wp-caption-text\">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 \u00a9 RECOVER<br \/><em>ALS\u2009=\u2009advanced life support; BLS\u2009=\u2009basic life support; CPR\u2009=\u2009cardiopulmonary resuscitation; ECG\u2009=\u2009electrocardiogram; ETCo2\u2009=\u2009end-tidal carbon dioxide PCA\u2009=\u2009post\u2013cardiac arrest; PEA\u2009=\u2009pulseless electrical activity; RECOVER\u2009=\u2009Reassessment Campaign on Veterinary Resuscitation; ROSC\u2009=\u2009return of spontaneous circulation; VF\u2009=\u2009ventricular fibrillation; VT\u2009=\u2009ventricular tachycardia<\/em><\/p><\/div>\n<h3 class=\"p3\">Initiating Basic Life Support<\/h3>\n<p class=\"p1\"><span class=\"s1\">BLS is designed to sustain the cardiorespiratory system in, apneic dogs and cats through external chest compressions and positive pressure ventilation. Unless a \u201cdo not resuscitate\u201d 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.<sup>2<\/sup><\/span><\/p>\n<p><span class=\"s1\">When a patient is found collapsed, the rescuer should first call for help and then evaluate the patient\u2019s responsiveness to tactile and auditory stimuli by employing the shake and shout method (<\/span><span class=\"s2\"><b>FIGURE 2<\/b><\/span><span class=\"s1\">). 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\u2013only CPR is recommended. Proper head and neck alignment during ventilation prevents airway obstruction.<sup>2<\/sup><\/span><\/p>\n<div id=\"attachment_127563\" style=\"width: 1904px\" class=\"wp-caption aligncenter\"><a href=\"https:\/\/todaysveterinarynurse.com\/wp-content\/uploads\/sites\/3\/2025\/03\/Yagi_RECOVERUpdate_TVNSpring25_Fig2.jpg\"><img decoding=\"async\" aria-describedby=\"caption-attachment-127563\" class=\"size-full wp-image-127563\" src=\"https:\/\/todaysveterinarynurse.com\/wp-content\/uploads\/sites\/3\/2025\/03\/Yagi_RECOVERUpdate_TVNSpring25_Fig2.jpg\" alt=\"\" width=\"1894\" height=\"1512\" srcset=\"https:\/\/navc.sitepreview.app\/todaysveterinarynurse.com\/wp-content\/uploads\/sites\/3\/2025\/03\/Yagi_RECOVERUpdate_TVNSpring25_Fig2.jpg 1894w, https:\/\/navc.sitepreview.app\/todaysveterinarynurse.com\/wp-content\/uploads\/sites\/3\/2025\/03\/Yagi_RECOVERUpdate_TVNSpring25_Fig2-300x239.jpg 300w, https:\/\/navc.sitepreview.app\/todaysveterinarynurse.com\/wp-content\/uploads\/sites\/3\/2025\/03\/Yagi_RECOVERUpdate_TVNSpring25_Fig2-1024x817.jpg 1024w, https:\/\/navc.sitepreview.app\/todaysveterinarynurse.com\/wp-content\/uploads\/sites\/3\/2025\/03\/Yagi_RECOVERUpdate_TVNSpring25_Fig2-768x613.jpg 768w, https:\/\/navc.sitepreview.app\/todaysveterinarynurse.com\/wp-content\/uploads\/sites\/3\/2025\/03\/Yagi_RECOVERUpdate_TVNSpring25_Fig2-1536x1226.jpg 1536w\" sizes=\"(max-width: 1894px) 100vw, 1894px\" \/><\/a><p id=\"caption-attachment-127563\" class=\"wp-caption-text\">Figure 2. The CPR initial assessment algorithm provides the logical flow in assessing an unresponsive patient leading into BLS. Courtesy \u00a9 RECOVER<br \/><em>BLS\u2009=\u2009basic life support; CPR\u2009=\u2009cardiopulmonary resuscitation<\/em><\/p><\/div>\n<p class=\"p1\"><span class=\"s1\">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\u00a0breath 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 H<sub>2<\/sub>O) should be present and functional. For anesthesia circuits, maintaining a peak airway pressure of 30 to 40 cm H<sub>2<\/sub>O during compressions is essential, reducing it to less than 20 cm H<sub>2<\/sub>O during the pause for rhythm assessment in between compression cycles.<sup>1<\/sup> 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.<sup>2<\/sup><\/span><\/p>\n<p class=\"p1\"><span class=\"s1\">Chest compressions in BLS vary based on the patient\u2019s 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\u2019s 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.<sup>2<\/sup><\/span><\/p>\n<h3 class=\"p3\">Initiating Advanced Life Support<\/h3>\n<p class=\"p1\"><span class=\"s1\">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.<sup>3<\/sup><\/span><\/p>\n<p class=\"p1\"><span class=\"s1\">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 (ETco<sub>2<\/sub>) value of \u2265<\/span><span class=\"s3\">\u2009<\/span><span class=\"s1\">12 mm Hg generally supports proper intubation, while a very low ETco<sub>2<\/sub> value (&lt;<\/span><span class=\"s3\">\u2009<\/span><span class=\"s1\">5\u00a0mm Hg) may signal issues requiring <\/span>verification by other methods (e.g., direct visualization)<span class=\"s1\">. Most important, capnography provides continuous feedback on chest compression quality, with an ETco<sub>2<\/sub> target of \u2265<\/span><span class=\"s3\">\u2009<\/span><span class=\"s1\">18 mm Hg indicating effective circulation. Keeping the ETco<sub>2<\/sub> above 18 mm Hg, and as high as possible, is thought to be the most impactful factor to achieving ROSC and positive neurologic outcome.<sup>3<\/sup><\/span><\/p>\n<p class=\"p1\"><span class=\"s1\">Treatment pathways in ALS are determined by the ECG rhythm identified during the \u201cpause and check\u201d following each 2-minute compression cycle (<\/span><span class=\"s2\"><b>FIGURES 1 AND 3<\/b><\/span><span class=\"s1\">). 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\u00a0minutes (every other cycle) (<\/span><span class=\"s2\"><b>FIGURE 4<\/b><\/span><span class=\"s1\">). If high vagal tone is suspected, a single dose of atropine (0.04 to 0.054\u00a0mg\/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.<sup>3<\/sup><\/span><\/p>\n<div id=\"attachment_127564\" style=\"width: 1900px\" class=\"wp-caption aligncenter\"><a href=\"https:\/\/todaysveterinarynurse.com\/wp-content\/uploads\/sites\/3\/2025\/03\/Yagi_RECOVERUpdate_TVNSpring25_Fig3.jpg\"><img decoding=\"async\" aria-describedby=\"caption-attachment-127564\" class=\"size-full wp-image-127564\" src=\"https:\/\/todaysveterinarynurse.com\/wp-content\/uploads\/sites\/3\/2025\/03\/Yagi_RECOVERUpdate_TVNSpring25_Fig3.jpg\" alt=\"\" width=\"1890\" height=\"1451\" srcset=\"https:\/\/navc.sitepreview.app\/todaysveterinarynurse.com\/wp-content\/uploads\/sites\/3\/2025\/03\/Yagi_RECOVERUpdate_TVNSpring25_Fig3.jpg 1890w, https:\/\/navc.sitepreview.app\/todaysveterinarynurse.com\/wp-content\/uploads\/sites\/3\/2025\/03\/Yagi_RECOVERUpdate_TVNSpring25_Fig3-300x230.jpg 300w, https:\/\/navc.sitepreview.app\/todaysveterinarynurse.com\/wp-content\/uploads\/sites\/3\/2025\/03\/Yagi_RECOVERUpdate_TVNSpring25_Fig3-1024x786.jpg 1024w, https:\/\/navc.sitepreview.app\/todaysveterinarynurse.com\/wp-content\/uploads\/sites\/3\/2025\/03\/Yagi_RECOVERUpdate_TVNSpring25_Fig3-768x590.jpg 768w, https:\/\/navc.sitepreview.app\/todaysveterinarynurse.com\/wp-content\/uploads\/sites\/3\/2025\/03\/Yagi_RECOVERUpdate_TVNSpring25_Fig3-1536x1179.jpg 1536w\" sizes=\"(max-width: 1890px) 100vw, 1890px\" \/><\/a><p id=\"caption-attachment-127564\" class=\"wp-caption-text\">Figure 3. The CPR ECG algorithm provides a simple and standard method to diagnosing ECG rhythms during the intercycle patient assessment. Courtesy \u00a9 RECOVER<br \/><em>CPR\u2009=\u2009cardiopulmonary resuscitation; ECG\u2009=\u2009electrocardiogram; PEA\u2009=\u2009pulseless electrical activity; ROSC\u2009=\u2009return of spontaneous circulation; VF\u2009=\u2009ventricular fibrillation; VT\u2009=\u2009ventricular tachycardia<\/em><\/p><\/div>\n<div id=\"attachment_127565\" style=\"width: 1903px\" class=\"wp-caption aligncenter\"><a href=\"https:\/\/todaysveterinarynurse.com\/wp-content\/uploads\/sites\/3\/2025\/03\/Yagi_RECOVERUpdate_TVNSpring25_Fig4.jpg\"><img loading=\"lazy\" decoding=\"async\" aria-describedby=\"caption-attachment-127565\" class=\"size-full wp-image-127565\" src=\"https:\/\/todaysveterinarynurse.com\/wp-content\/uploads\/sites\/3\/2025\/03\/Yagi_RECOVERUpdate_TVNSpring25_Fig4.jpg\" alt=\"\" width=\"1893\" height=\"1250\" srcset=\"https:\/\/navc.sitepreview.app\/todaysveterinarynurse.com\/wp-content\/uploads\/sites\/3\/2025\/03\/Yagi_RECOVERUpdate_TVNSpring25_Fig4.jpg 1893w, https:\/\/navc.sitepreview.app\/todaysveterinarynurse.com\/wp-content\/uploads\/sites\/3\/2025\/03\/Yagi_RECOVERUpdate_TVNSpring25_Fig4-300x198.jpg 300w, https:\/\/navc.sitepreview.app\/todaysveterinarynurse.com\/wp-content\/uploads\/sites\/3\/2025\/03\/Yagi_RECOVERUpdate_TVNSpring25_Fig4-1024x676.jpg 1024w, https:\/\/navc.sitepreview.app\/todaysveterinarynurse.com\/wp-content\/uploads\/sites\/3\/2025\/03\/Yagi_RECOVERUpdate_TVNSpring25_Fig4-768x507.jpg 768w, https:\/\/navc.sitepreview.app\/todaysveterinarynurse.com\/wp-content\/uploads\/sites\/3\/2025\/03\/Yagi_RECOVERUpdate_TVNSpring25_Fig4-1536x1014.jpg 1536w\" sizes=\"(max-width: 1893px) 100vw, 1893px\" \/><\/a><p id=\"caption-attachment-127565\" class=\"wp-caption-text\">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 \u00a9 RECOVER<\/p><\/div>\n<h3 class=\"p3\">Following CPR Flow<\/h3>\n<p class=\"p1\"><span class=\"s1\">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 (<\/span><span class=\"s2\"><b>FIGURE 3<\/b><\/span><span class=\"s1\">). 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 <\/span><span class=\"s4\">\u03b2<\/span><span class=\"s1\">-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 &lt;<\/span><span class=\"s3\">\u2009<\/span><span class=\"s1\">7).<\/span><\/p>\n<p class=\"p1\"><span class=\"s1\">Decisions about discontinuing CPR follow precise criteria. If the team identifies a palpable femoral pulse during the 10-second \u201cpause and check\u201d or observes a sudden and sustained rise in ETco<sub>2<\/sub> (e.g., by \u2265<\/span><span class=\"s3\">\u2009<\/span><span class=\"s1\">10 mm Hg to a level \u2265<\/span><span class=\"s3\">\u2009<\/span><span class=\"s1\">35 mm Hg) coupled with an arterial pulse distinct from compressions, ROSC is confirmed, and resuscitation efforts should shift to post\u2013cardiac arrest care. If neither ROSC nor signs of improvement occur despite exhaustive efforts, the team may decide to cease resuscitation based on the patient\u2019s condition and prognosis.<\/span><\/p>\n<p class=\"p1\"><span class=\"s1\">High-quality BLS combined with ALS interventions are essential to restoring spontaneous circulation, regardless of the arrest\u2019s 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 (<\/span><span class=\"s2\"><b>FIGURE 1<\/b><\/span><span class=\"s1\">). Teams are encouraged to familiarize themselves with the full guidelines, available at <\/span><a href=\"http:\/\/recoverinitiative.org\" target=\"_blank\" rel=\"noopener\"><span class=\"s2\">recoverinitiative.org<\/span><\/a><span class=\"s1\">, to refine their clinical decision-making and optimize outcomes.<\/span><\/p>\n<h2 class=\"p2\">Key Updates in the 2024 Guidelines<\/h2>\n<h3 class=\"p3\">Chest Compressions in Wide-Chested Animals<\/h3>\n<p class=\"p1\"><span class=\"s1\">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.<\/span><\/p>\n<p class=\"p1\"><span class=\"s1\">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\u2019s 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 (<\/span><span class=\"s2\"><b>FIGURE 5<\/b><\/span><span class=\"s1\">).<\/span><\/p>\n<div class=\"su-image-carousel  su-image-carousel-has-spacing su-image-carousel-crop su-image-carousel-crop-5-4 su-image-carousel-has-lightbox su-image-carousel-has-outline su-image-carousel-adaptive su-image-carousel-slides-style-default su-image-carousel-controls-style-dark su-image-carousel-align-center\" style=\"max-width:70%\" data-flickity-options='{\"groupCells\":true,\"cellSelector\":\".su-image-carousel-item\",\"adaptiveHeight\":false,\"cellAlign\":\"left\",\"prevNextButtons\":true,\"pageDots\":false,\"autoPlay\":5000,\"imagesLoaded\":true,\"contain\":true,\"selectedAttraction\":0.025,\"friction\":0.28}' id=\"su_image_carousel_69e8e8fc60365\"><div class=\"su-image-carousel-item\"><div class=\"su-image-carousel-item-content\"><a href=\"https:\/\/navc.sitepreview.app\/todaysveterinarynurse.com\/wp-content\/uploads\/sites\/3\/2025\/03\/Yagi_RECOVERUpdate_TVNSpring25_Fig5A.png\" target=\"_blank\" rel=\"noopener noreferrer\" data-caption=\"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\"><img loading=\"lazy\" decoding=\"async\" width=\"1024\" height=\"558\" src=\"https:\/\/navc.sitepreview.app\/todaysveterinarynurse.com\/wp-content\/uploads\/sites\/3\/2025\/03\/Yagi_RECOVERUpdate_TVNSpring25_Fig5A-1024x558.png\" class=\"\" alt=\"\" srcset=\"https:\/\/navc.sitepreview.app\/todaysveterinarynurse.com\/wp-content\/uploads\/sites\/3\/2025\/03\/Yagi_RECOVERUpdate_TVNSpring25_Fig5A-1024x558.png 1024w, https:\/\/navc.sitepreview.app\/todaysveterinarynurse.com\/wp-content\/uploads\/sites\/3\/2025\/03\/Yagi_RECOVERUpdate_TVNSpring25_Fig5A-300x163.png 300w, https:\/\/navc.sitepreview.app\/todaysveterinarynurse.com\/wp-content\/uploads\/sites\/3\/2025\/03\/Yagi_RECOVERUpdate_TVNSpring25_Fig5A-768x418.png 768w, https:\/\/navc.sitepreview.app\/todaysveterinarynurse.com\/wp-content\/uploads\/sites\/3\/2025\/03\/Yagi_RECOVERUpdate_TVNSpring25_Fig5A-1536x837.png 1536w, https:\/\/navc.sitepreview.app\/todaysveterinarynurse.com\/wp-content\/uploads\/sites\/3\/2025\/03\/Yagi_RECOVERUpdate_TVNSpring25_Fig5A.png 1889w\" sizes=\"(max-width: 1024px) 100vw, 1024px\" \/><span>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<\/span><\/a><\/div><\/div><div class=\"su-image-carousel-item\"><div class=\"su-image-carousel-item-content\"><a href=\"https:\/\/navc.sitepreview.app\/todaysveterinarynurse.com\/wp-content\/uploads\/sites\/3\/2025\/03\/Yagi_RECOVERUpdate_TVNSpring25_Fig5B.png\" target=\"_blank\" rel=\"noopener noreferrer\" data-caption=\"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\"><img loading=\"lazy\" decoding=\"async\" width=\"935\" height=\"765\" src=\"https:\/\/navc.sitepreview.app\/todaysveterinarynurse.com\/wp-content\/uploads\/sites\/3\/2025\/03\/Yagi_RECOVERUpdate_TVNSpring25_Fig5B.png\" class=\"\" alt=\"\" srcset=\"https:\/\/navc.sitepreview.app\/todaysveterinarynurse.com\/wp-content\/uploads\/sites\/3\/2025\/03\/Yagi_RECOVERUpdate_TVNSpring25_Fig5B.png 935w, https:\/\/navc.sitepreview.app\/todaysveterinarynurse.com\/wp-content\/uploads\/sites\/3\/2025\/03\/Yagi_RECOVERUpdate_TVNSpring25_Fig5B-300x245.png 300w, https:\/\/navc.sitepreview.app\/todaysveterinarynurse.com\/wp-content\/uploads\/sites\/3\/2025\/03\/Yagi_RECOVERUpdate_TVNSpring25_Fig5B-768x628.png 768w\" sizes=\"(max-width: 935px) 100vw, 935px\" \/><span>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<\/span><\/a><\/div><\/div><div class=\"su-image-carousel-item\"><div class=\"su-image-carousel-item-content\"><a href=\"https:\/\/navc.sitepreview.app\/todaysveterinarynurse.com\/wp-content\/uploads\/sites\/3\/2025\/03\/Yagi_RECOVERUpdate_TVNSpring25_Fig5C.jpg\" target=\"_blank\" rel=\"noopener noreferrer\" data-caption=\"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\"><img loading=\"lazy\" decoding=\"async\" width=\"929\" height=\"765\" src=\"https:\/\/navc.sitepreview.app\/todaysveterinarynurse.com\/wp-content\/uploads\/sites\/3\/2025\/03\/Yagi_RECOVERUpdate_TVNSpring25_Fig5C.jpg\" class=\"\" alt=\"\" srcset=\"https:\/\/navc.sitepreview.app\/todaysveterinarynurse.com\/wp-content\/uploads\/sites\/3\/2025\/03\/Yagi_RECOVERUpdate_TVNSpring25_Fig5C.jpg 929w, https:\/\/navc.sitepreview.app\/todaysveterinarynurse.com\/wp-content\/uploads\/sites\/3\/2025\/03\/Yagi_RECOVERUpdate_TVNSpring25_Fig5C-300x247.jpg 300w, https:\/\/navc.sitepreview.app\/todaysveterinarynurse.com\/wp-content\/uploads\/sites\/3\/2025\/03\/Yagi_RECOVERUpdate_TVNSpring25_Fig5C-768x632.jpg 768w\" sizes=\"(max-width: 929px) 100vw, 929px\" \/><span>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<\/span><\/a><\/div><\/div><\/div><script id=\"su_image_carousel_69e8e8fc60365_script\">if(window.SUImageCarousel){setTimeout(function() {window.SUImageCarousel.initGallery(document.getElementById(\"su_image_carousel_69e8e8fc60365\"))}, 0);}var su_image_carousel_69e8e8fc60365_script=document.getElementById(\"su_image_carousel_69e8e8fc60365_script\");if(su_image_carousel_69e8e8fc60365_script){su_image_carousel_69e8e8fc60365_script.parentNode.removeChild(su_image_carousel_69e8e8fc60365_script);}<\/script>\n<h3 class=\"p3\">Recumbency During Intubation for Wide-Chested Animals<\/h3>\n<p class=\"p1\"><span class=\"s1\">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 ETco<sub>2<\/sub>, 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.<\/span><\/p>\n<h3 class=\"p3\">Compression Techniques for Small Dogs and Cats<\/h3>\n<p class=\"p4\"><span class=\"s1\">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\u2019s 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\u2019s size and anatomy.<\/span><\/p>\n<p><span class=\"s1\"><b>1. Circumferential (2-thumb) technique:<\/b> 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 (<\/span><span class=\"s2\"><b>FIGURE 6A<\/b><\/span><span class=\"s1\">).<\/span><\/p>\n<div id=\"attachment_127569\" style=\"width: 310px\" class=\"wp-caption aligncenter\"><a href=\"https:\/\/todaysveterinarynurse.com\/wp-content\/uploads\/sites\/3\/2025\/03\/Yagi_RECOVERUpdate_TVNSpring25_Fig6A.png\"><img loading=\"lazy\" decoding=\"async\" aria-describedby=\"caption-attachment-127569\" class=\" wp-image-127569\" src=\"https:\/\/todaysveterinarynurse.com\/wp-content\/uploads\/sites\/3\/2025\/03\/Yagi_RECOVERUpdate_TVNSpring25_Fig6A.png\" alt=\"\" width=\"300\" height=\"243\" srcset=\"https:\/\/navc.sitepreview.app\/todaysveterinarynurse.com\/wp-content\/uploads\/sites\/3\/2025\/03\/Yagi_RECOVERUpdate_TVNSpring25_Fig6A.png 858w, https:\/\/navc.sitepreview.app\/todaysveterinarynurse.com\/wp-content\/uploads\/sites\/3\/2025\/03\/Yagi_RECOVERUpdate_TVNSpring25_Fig6A-300x243.png 300w, https:\/\/navc.sitepreview.app\/todaysveterinarynurse.com\/wp-content\/uploads\/sites\/3\/2025\/03\/Yagi_RECOVERUpdate_TVNSpring25_Fig6A-768x623.png 768w\" sizes=\"(max-width: 300px) 100vw, 300px\" \/><\/a><p id=\"caption-attachment-127569\" class=\"wp-caption-text\">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<\/p><\/div>\n<p class=\"p5\"><span class=\"s1\"><b>2. One-Handed Technique:<\/b> 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\u2019s back. This technique provides precise control and reduces the risk of overcompression, making it an excellent option for adult cats and small dogs (<\/span><span class=\"s2\"><b>FIGURE 6B<\/b><\/span><span class=\"s1\">).<\/span><\/p>\n<div id=\"attachment_127570\" style=\"width: 310px\" class=\"wp-caption aligncenter\"><a href=\"https:\/\/todaysveterinarynurse.com\/wp-content\/uploads\/sites\/3\/2025\/03\/Yagi_RECOVERUpdate_TVNSpring25_Fig6B.png\"><img loading=\"lazy\" decoding=\"async\" aria-describedby=\"caption-attachment-127570\" class=\" wp-image-127570\" src=\"https:\/\/todaysveterinarynurse.com\/wp-content\/uploads\/sites\/3\/2025\/03\/Yagi_RECOVERUpdate_TVNSpring25_Fig6B.png\" alt=\"\" width=\"300\" height=\"243\" srcset=\"https:\/\/navc.sitepreview.app\/todaysveterinarynurse.com\/wp-content\/uploads\/sites\/3\/2025\/03\/Yagi_RECOVERUpdate_TVNSpring25_Fig6B.png 858w, https:\/\/navc.sitepreview.app\/todaysveterinarynurse.com\/wp-content\/uploads\/sites\/3\/2025\/03\/Yagi_RECOVERUpdate_TVNSpring25_Fig6B-300x243.png 300w, https:\/\/navc.sitepreview.app\/todaysveterinarynurse.com\/wp-content\/uploads\/sites\/3\/2025\/03\/Yagi_RECOVERUpdate_TVNSpring25_Fig6B-768x622.png 768w\" sizes=\"(max-width: 300px) 100vw, 300px\" \/><\/a><p id=\"caption-attachment-127570\" class=\"wp-caption-text\">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<\/p><\/div>\n<p class=\"p6\"><span class=\"s1\"><b>3. Heel of the hand technique:<\/b> 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 ETco<sub>2<\/sub> levels. This technique may be required for small dogs of intermediate size with stiff enough chests that the 1-handed technique is not sustainable (<\/span><span class=\"s2\"><b>FIGURE 6C<\/b><\/span><span class=\"s1\">).<\/span><\/p>\n<div id=\"attachment_127571\" style=\"width: 310px\" class=\"wp-caption aligncenter\"><a href=\"https:\/\/todaysveterinarynurse.com\/wp-content\/uploads\/sites\/3\/2025\/03\/Yagi_RECOVERUpdate_TVNSpring25_Fig6C.jpg\"><img loading=\"lazy\" decoding=\"async\" aria-describedby=\"caption-attachment-127571\" class=\" wp-image-127571\" src=\"https:\/\/todaysveterinarynurse.com\/wp-content\/uploads\/sites\/3\/2025\/03\/Yagi_RECOVERUpdate_TVNSpring25_Fig6C.jpg\" alt=\"\" width=\"300\" height=\"244\" srcset=\"https:\/\/navc.sitepreview.app\/todaysveterinarynurse.com\/wp-content\/uploads\/sites\/3\/2025\/03\/Yagi_RECOVERUpdate_TVNSpring25_Fig6C.jpg 858w, https:\/\/navc.sitepreview.app\/todaysveterinarynurse.com\/wp-content\/uploads\/sites\/3\/2025\/03\/Yagi_RECOVERUpdate_TVNSpring25_Fig6C-300x244.jpg 300w, https:\/\/navc.sitepreview.app\/todaysveterinarynurse.com\/wp-content\/uploads\/sites\/3\/2025\/03\/Yagi_RECOVERUpdate_TVNSpring25_Fig6C-768x625.jpg 768w\" sizes=\"(max-width: 300px) 100vw, 300px\" \/><\/a><p id=\"caption-attachment-127571\" class=\"wp-caption-text\">Figure 6C. Heel of the hand technique: This approach uses the heel of 1\u00a0hand 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<\/p><\/div>\n<p class=\"p1\"><span class=\"s1\">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 ETco<sub>2<\/sub> monitoring to assess the effectiveness of compressions, ensuring blood flow is optimized throughout resuscitation efforts.<\/span><\/p>\n<h3 class=\"p3\">Nonintubated Ventilation<\/h3>\n<p class=\"p1\"><span class=\"s1\">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.<\/span><\/p>\n<p class=\"p1\"><span class=\"s1\">For nonintubated animals, ventilation is recommended over chest compression\u2013only 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\u2013only CPR is acceptable as a temporary measure until equipment or intubation becomes available.<\/span><\/p>\n<p class=\"p1\"><span class=\"s1\">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.<\/span><\/p>\n<h3 class=\"p3\">Increased ETco<sub>2<\/sub> Targets in CPR<\/h3>\n<p class=\"p1\"><span class=\"s1\">The 2024 RECOVER guidelines raise the target for ETco<sub>2<\/sub> levels during CPR from 15 mm Hg to 18 mm Hg, reflecting new evidence that higher ETco<sub>2<\/sub> values correlate with improved outcomes.<sup>1,4-6<\/sup> ETco<sub>2<\/sub> serves as a critical indicator of blood flow generated by chest compressions, with higher values indicating better circulation, oxygen delivery, and cellular energy production.<sup>4-6 <\/sup> 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.<\/span><\/p>\n<p class=\"p1\"><span class=\"s1\">Previous guidelines set the ETco<sub>2<\/sub> 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.<sup>7,8<\/sup> However, newer observational studies suggest that higher ETco<sub>2<\/sub> values, closer to 18\u00a0mm Hg or above, are more effective discriminators for successful outcomes without associated harm.<sup>1,4-6 <\/sup> 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 ETco<sub>2<\/sub> 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 ETco<sub>2<\/sub> for each patient (<\/span><span class=\"s2\"><b>FIGURE 7<\/b><\/span><span class=\"s1\">).<\/span><\/p>\n<div id=\"attachment_127572\" style=\"width: 311px\" class=\"wp-caption aligncenter\"><a href=\"https:\/\/todaysveterinarynurse.com\/wp-content\/uploads\/sites\/3\/2025\/03\/Yagi_RECOVERUpdate_TVNSpring25_Fig7.png\"><img loading=\"lazy\" decoding=\"async\" aria-describedby=\"caption-attachment-127572\" class=\" wp-image-127572\" src=\"https:\/\/todaysveterinarynurse.com\/wp-content\/uploads\/sites\/3\/2025\/03\/Yagi_RECOVERUpdate_TVNSpring25_Fig7.png\" alt=\"\" width=\"301\" height=\"241\" srcset=\"https:\/\/navc.sitepreview.app\/todaysveterinarynurse.com\/wp-content\/uploads\/sites\/3\/2025\/03\/Yagi_RECOVERUpdate_TVNSpring25_Fig7.png 864w, https:\/\/navc.sitepreview.app\/todaysveterinarynurse.com\/wp-content\/uploads\/sites\/3\/2025\/03\/Yagi_RECOVERUpdate_TVNSpring25_Fig7-300x240.png 300w, https:\/\/navc.sitepreview.app\/todaysveterinarynurse.com\/wp-content\/uploads\/sites\/3\/2025\/03\/Yagi_RECOVERUpdate_TVNSpring25_Fig7-768x614.png 768w\" sizes=\"(max-width: 301px) 100vw, 301px\" \/><\/a><p id=\"caption-attachment-127572\" class=\"wp-caption-text\">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.<\/p><\/div>\n<p class=\"p1\"><span class=\"s1\">Importantly, this update emphasizes that ETco<sub>2<\/sub> 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 ETco<sub>2<\/sub> levels as high as possible for the patient. Higher ETco<sub>2<\/sub> values are linked not only to better chances of ROSC but also to improved postresuscitation outcomes,<sup>4,9,10<\/sup> emphasizing their significance in guiding effective resuscitation efforts.<\/span><\/p>\n<h3 class=\"p3\">High-Dose Epinephrine Removed From Guidelines<\/h3>\n<p class=\"p1\"><span class=\"s1\">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.<sup>3,11-14<\/sup> This could negatively affect neurologic outcomes, which are crucial for postresuscitation quality of life.<\/span><\/p>\n<p class=\"p1\"><span class=\"s1\">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.<sup>3,12-14<\/sup> Even ROSC rates were inconsistent, with studies showing mixed results: some indicating a benefit, others showing no effect, and a few suggesting harm.<sup>12,13,15,16<\/sup> 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.<\/span><\/p>\n<p class=\"p1\"><span class=\"s1\">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.<\/span><\/p>\n<h3 class=\"p3\">Give Atropine Once, As Soon As Determined to Be Needed<\/h3>\n<p class=\"p1\"><span class=\"s1\">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.<\/span><\/p>\n<p class=\"p1\"><span class=\"s1\">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.<sup>2<\/sup> 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\u2013cardiac arrest period. Additionally, higher doses have shown evidence of harm in experimental studies,<sup>3,17<\/sup> reinforcing the importance of avoiding repeated administration.<\/span><\/p>\n<p class=\"p1\"><span class=\"s1\">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,<sup>3,18,19<\/sup> while studies in humans and other species have shown mixed results.<sup>3,17,19,20<\/sup> 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.<\/span><\/p>\n<p class=\"p1\"><span class=\"s1\">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.<\/span><\/p>\n<h3 class=\"p3\">Changes to Treating Refractory Shockable Rhythms<\/h3>\n<p class=\"p1\"><span class=\"s1\">Guidelines on the treatments for refractory shockable rhythms have been refined to improve clarity, efficiency, and outcomes. A <i>refractory shockable rhythm<\/i> 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.<\/span><\/p>\n<p class=\"p7\"><b>Adjustments to Defibrillation Protocols<\/b><\/p>\n<p class=\"p1\"><span class=\"s1\">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.<sup>3,21-25<\/sup> 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.<\/span><\/p>\n<p class=\"p7\"><b>Vasopressors<\/b><\/p>\n<p class=\"p1\"><span class=\"s1\">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 <\/span><span class=\"s4\">\u03b2<\/span><span class=\"s1\"><sub>1<\/sub>-mediated proarrhythmogenic effects of epinephrine.<\/span><\/p>\n<p class=\"p7\"><b>Antiarrhythmics<\/b><\/p>\n<p class=\"p1\"><span class=\"s1\">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.<sup>3,8<\/sup> 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.<sup>26<\/sup> Aqueous formulations of amiodarone are considered safer but require large infusion volumes, making them less practical during CPR.<\/span><\/p>\n<p class=\"p7\"><b>\u03b2-Blockers<\/b><\/p>\n<p class=\"p1\"><span class=\"s1\">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 \u00b5g\/kg\/min) in cases where shockable rhythms persist after the first defibrillation. Esmolol, a <\/span><span class=\"s4\">\u03b2<\/span><span class=\"s1\"><sub>1<\/sub>-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.<sup>3,27-35<\/sup> The <\/span><span class=\"s4\">\u03b2<\/span><span class=\"s1\"><sub>1<\/sub>-specific nature of esmolol minimizes the risk of bronchoconstriction associated with nonselective <\/span><span class=\"s4\">\u03b2<\/span><span class=\"s1\">-blockers like propranolol.<\/span><\/p>\n<p class=\"p7\"><b>Practical Implications<\/b><\/p>\n<p class=\"p1\"><span class=\"s1\">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.<\/span><\/p>\n<h2 class=\"p2\">The RECOVER Initiative<\/h2>\n<p class=\"p1\"><span class=\"s1\">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.<\/span><\/p>\n<p class=\"p1\"><span class=\"s1\">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.<\/span><\/p>\n<p class=\"p1\"><span class=\"s1\">A common question often asked about investing efforts in CPR education and training is, \u201cIs it worth it? The chances of success are so low.\u201d 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. <\/span><\/p>\n<p class=\"p8\"><b>Disclosure<\/b><\/p>\n<p class=\"p9\"><span class=\"s1\">Kenichiro Yagi is the program director for the RECOVER Initiative.<\/span><\/p>\n","protected":false},"excerpt":{"rendered":"<p>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 cardiopulmonary arrest.<\/p>\n","protected":false},"author":236,"featured_media":127573,"comment_status":"open","ping_status":"open","sticky":false,"template":"","format":"standard","meta":{"_acf_changed":false,"iawp_total_views":0,"footnotes":""},"categories":[811],"tags":[192,145],"class_list":["post-127557","post","type-post","status-publish","format-standard","has-post-thumbnail","hentry","category-spring-2025","tag-continuing-education","tag-peer-reviewed","column-continuing-education","column-features","clinical_topics-emergency-medicine-critical-care"],"acf":{"hide_sidebar":false,"hide_sidebar_ad":false,"hide_all_ads":false},"yoast_head":"<!-- This site is optimized with the Yoast SEO Premium plugin v24.7 (Yoast SEO v27.4) - https:\/\/yoast.com\/product\/yoast-seo-premium-wordpress\/ -->\n<title>Key Updates From the 2024 RECOVER Guidelines | Today&#039;s Veterinary Nurse<\/title>\n<meta name=\"description\" content=\"The updated RECOVER guidelines represent a vital step forward in the 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