{"id":1135,"date":"2014-01-01T16:41:54","date_gmt":"2014-01-01T16:41:54","guid":{"rendered":"http:\/\/phosdev.com\/todaysveterinarypractice\/?p=1135"},"modified":"2022-02-16T19:15:40","modified_gmt":"2022-02-16T19:15:40","slug":"cardiopulmonary-resuscitation-the-recover-guidelines","status":"publish","type":"post","link":"https:\/\/navc.sitepreview.app\/todaysveterinarypractice.com\/emergency-medicine-critical-care\/cardiopulmonary-resuscitation-the-recover-guidelines\/","title":{"rendered":"CPR for Dogs and Cats: The RECOVER Guidelines for Veterinary Resuscitation"},"content":{"rendered":"<p class=\"p1\"><span class=\"s1\">The author presents the RECOVER initiative, which created the first consensus guidelines on veterinary resuscitation, and discusses the 5 domains of CPR for dogs and cats: preparedness and prevention, basic life support, advanced life support, monitoring, and post cardiac arrest care.<\/span><\/p>\n<hr \/>\n<p class=\"p1\"><span class=\"s1\">Management of cardiopulmonary arrest (CPA) requires rapid patient assessment, with immediate institution of cardiopulmonary resuscitation (CPR) for dogs and cats. <\/span><\/p>\n<p class=\"p1\"><span class=\"s1\">Despite amazing advances in veterinary medicine over the last several years, over 90% of dogs and cats do not survive CPA.<\/span><span class=\"s2\"><sup>1<\/sup><\/span><span class=\"s1\"> Human and veterinary CPA patients had similar outcomes before the institution of evidence-based guidelines and mandatory comprehensive training of human health care professionals.<\/span><span class=\"s2\"><sup>1<\/sup><\/span><span class=\"s1\"> Now approximately 20% of humans survive in-hospital CPA.<\/span><span class=\"s2\"><sup>1<\/sup><\/span><\/p>\n<p class=\"p1\"><span class=\"s1\">The improved outcomes in human survival are largely considered to be a product of the guidelines and standardized training mentioned above. With this in mind, the Reassessment Campaign on Veterinary Resuscitation (RECOVER) was developed. The RECOVER initiative had 2 goals: <\/span><\/p>\n<ul class=\"ul1\">\n<li class=\"li1\"><span class=\"s1\">Develop evidence-based guidelines for dogs and cats experiencing CPA<\/span><\/li>\n<li class=\"li1\"><span class=\"s1\">Identify knowledge gaps, or areas of CPA management that require further investigation.<\/span><span class=\"s2\"><sup>1<\/sup><\/span><\/li>\n<\/ul>\n<p class=\"p1\"><span class=\"s1\">Both goals have the same ultimate objective: to improve the quality and outcomes of veterinary resuscitation efforts. The RECOVER initiative is an ongoing process, combining evaluation of available evidence to develop current best practices and reevaluation in the future.<\/span><span class=\"s2\"><sup>1<\/sup><\/span><\/p>\n<p class=\"p1\"><span class=\"s1\">This article provides an overview of the guidelines; however, readers are encouraged to read the original manuscript (see <b>Read the RECOVER Guidelines<\/b>).<\/span><\/p>\n<div class=\"orange-box\">\n<h3 class=\"p1\"><span class=\"s1\">Read the RECOVER Guidelines<\/span><\/h3>\n<p class=\"p1\"><span class=\"s1\">The RECOVER initiative&#8217;s evidence-based guidelines were published in a special issue of the Journal of Veterinary Emergency and Critical Care in 2012; these guidelines can be downloaded for free at <b>veccs.org<\/b>.<\/span><span class=\"s2\"><sup><span style=\"font-size: small\">1<\/span><\/sup><\/span><\/p>\n<p class=\"p1\"><span class=\"s1\">The RECOVER initiative also developed 3 posters for use in clinical practice\u2014CPR Emergency Drugs and Doses, CPR Algorithm, and PCA Algorithm.<sup>1,2<\/sup> These posters are available for purchase at <b>veccs.org<\/b>. The Veterinary Emergency and Critical Care Society kindly granted permission for adapted versions of the <b>CPR Emergency Drugs and Doses<\/b> and the <b>CPR Algorithm<\/b> below.<\/span><\/p>\n<\/div>\n<p class=\"p3\"><a href=\"https:\/\/todaysveterinarypractice.com\/wp-content\/uploads\/sites\/4\/2014\/01\/Screen-Shot-2015-06-18-at-3.32.10-PM.png\"><img fetchpriority=\"high\" decoding=\"async\" class=\"alignnone wp-image-4864\" src=\"https:\/\/todaysveterinarypractice.com\/wp-content\/uploads\/sites\/4\/2014\/01\/Screen-Shot-2015-06-18-at-3.32.10-PM.png\" alt=\"Screen Shot 2015-06-18 at 3.32.10 PM\" width=\"476\" height=\"373\" srcset=\"https:\/\/navc.sitepreview.app\/todaysveterinarypractice.com\/wp-content\/uploads\/sites\/4\/2014\/01\/Screen-Shot-2015-06-18-at-3.32.10-PM.png 574w, https:\/\/navc.sitepreview.app\/todaysveterinarypractice.com\/wp-content\/uploads\/sites\/4\/2014\/01\/Screen-Shot-2015-06-18-at-3.32.10-PM-300x235.png 300w\" sizes=\"(max-width: 476px) 100vw, 476px\" \/><\/a><\/p>\n<p class=\"p3\"><a href=\"https:\/\/todaysveterinarypractice.com\/wp-content\/uploads\/sites\/4\/2014\/01\/Screen-Shot-2015-06-18-at-3.32.47-PM.png\"><img decoding=\"async\" class=\"alignnone wp-image-4865\" src=\"https:\/\/todaysveterinarypractice.com\/wp-content\/uploads\/sites\/4\/2014\/01\/Screen-Shot-2015-06-18-at-3.32.47-PM.png\" alt=\"Screen Shot 2015-06-18 at 3.32.47 PM\" width=\"491\" height=\"586\" srcset=\"https:\/\/navc.sitepreview.app\/todaysveterinarypractice.com\/wp-content\/uploads\/sites\/4\/2014\/01\/Screen-Shot-2015-06-18-at-3.32.47-PM.png 561w, https:\/\/navc.sitepreview.app\/todaysveterinarypractice.com\/wp-content\/uploads\/sites\/4\/2014\/01\/Screen-Shot-2015-06-18-at-3.32.47-PM-252x300.png 252w\" sizes=\"(max-width: 491px) 100vw, 491px\" \/><\/a><\/p>\n<h2 class=\"p3\"><span class=\"s1\"><b>RECOVER GUIDELINES<\/b><\/span><\/h2>\n<p class=\"p1\"><span class=\"s1\">The RECOVER guidelines are divided into 5 major topics, or <strong>domains<\/strong>, which provided structure for the development process:<\/span><span class=\"s2\"><sup>1<\/sup><\/span><\/p>\n<ol class=\"ol1\">\n<li class=\"li1\"><span class=\"s1\">Preparedness and prevention<\/span><\/li>\n<li class=\"li1\"><span class=\"s1\">Basic life support (BLS) <\/span><\/li>\n<li class=\"li1\"><span class=\"s1\">Advanced life support (ALS)<\/span><\/li>\n<li class=\"li1\"><span class=\"s1\">Monitoring<\/span><\/li>\n<li class=\"li1\"><span class=\"s1\">Post cardiac arrest (PCA) care.<\/span><\/li>\n<\/ol>\n<p class=\"p1\"><span class=\"s1\">A total of 101 clinical guidelines were developed and published, with the guidelines organized by domain.<\/span><span class=\"s2\"><sup>1,2<\/sup><\/span><span class=\"s1\"> The guidelines are further categorized by Class and Level (see <b>RECOVER Classes &amp; Levels<\/b>).<\/span><\/p>\n<div class=\"orange-box\">\n<p class=\"p3\"><span class=\"s1\"><b>RECOVER Classes &amp; Levels<\/b><\/span><\/p>\n<p class=\"p1\"><span class=\"s1\">Each guideline was assigned a class and level based on the initiative&#8217;s findings (<b>Table<\/b>).<\/span><span class=\"s2\"><sup><span style=\"font-size: small\">1<\/span><\/sup><\/span><span class=\"s1\"> For example, the recommendation to perform chest compressions at 100 to 120 compressions per minute is a Class I, Level A recommendation, which means:<\/span><span class=\"s2\"><sup><span style=\"font-size: small\">2,4<\/span><\/sup><\/span><\/p>\n<ul class=\"ul1\">\n<li class=\"li1\"><span class=\"s1\">The benefit of performing chest compressions at 100 to 120 compressions per minute greatly outweighs the risk of performing them at another rate (<strong>Class<\/strong>)<\/span><\/li>\n<li class=\"li1\"><span class=\"s1\">There are multiple, high-quality studies in multiple populations that support this recommendation (<b>Level<\/b>).<\/span><\/li>\n<\/ul>\n<p class=\"p1\"><span class=\"s1\">\u00a0<a href=\"https:\/\/todaysveterinarypractice.com\/wp-content\/uploads\/sites\/4\/2014\/01\/Screen-Shot-2015-05-14-at-3.48.43-PM.png\"><img decoding=\"async\" class=\"alignnone size-medium wp-image-4041\" src=\"https:\/\/todaysveterinarypractice.com\/wp-content\/uploads\/sites\/4\/2014\/01\/Screen-Shot-2015-05-14-at-3.48.43-PM-300x192.png\" alt=\"Screen Shot 2015-05-14 at 3.48.43 PM\" width=\"300\" height=\"192\" srcset=\"https:\/\/navc.sitepreview.app\/todaysveterinarypractice.com\/wp-content\/uploads\/sites\/4\/2014\/01\/Screen-Shot-2015-05-14-at-3.48.43-PM-300x192.png 300w, https:\/\/navc.sitepreview.app\/todaysveterinarypractice.com\/wp-content\/uploads\/sites\/4\/2014\/01\/Screen-Shot-2015-05-14-at-3.48.43-PM-768x491.png 768w, https:\/\/navc.sitepreview.app\/todaysveterinarypractice.com\/wp-content\/uploads\/sites\/4\/2014\/01\/Screen-Shot-2015-05-14-at-3.48.43-PM.png 894w\" sizes=\"(max-width: 300px) 100vw, 300px\" \/><\/a><\/span><\/p>\n<\/div>\n<h2 class=\"p3\"><span class=\"s1\"><b>DOMAIN 1: PREVENTION &amp; PREPAREDNESS<\/b><\/span><\/h2>\n<h3 class=\"p4\"><span class=\"s1\"><b>Equipment &amp; Training<\/b><\/span><\/h3>\n<p class=\"p1\"><span class=\"s1\">The prevention and preparedness guidelines are directed at improving CPA equipment availability, training, and teamwork, and include ensuring: <\/span><\/p>\n<ul class=\"ul1\">\n<li class=\"li1\"><span class=\"s1\">Staff are familiar with and utilize a standardized crash cart (<b>Figure 1<\/b>) or pre-stocked arrest stations (<strong>I-A<\/strong>)<\/span><\/li>\n<li class=\"li1\"><span class=\"s1\">Cognitive aids are available for review during a CPR event (<strong>I-B<\/strong>)<\/span><\/li>\n<li class=\"li1\"><span class=\"s1\">Staff receive comprehensive multimodal training, including simulations, followed by structured assessment to determine comprehension (<strong>I-A<\/strong>).<\/span><span class=\"s2\"><sup>2,3<\/sup><\/span><\/li>\n<\/ul>\n<div id=\"attachment_4035\" style=\"width: 310px\" class=\"wp-caption alignnone\"><a href=\"https:\/\/todaysveterinarypractice.com\/wp-content\/uploads\/sites\/4\/2014\/01\/TT_Figure-1.jpg\"><img loading=\"lazy\" decoding=\"async\" aria-describedby=\"caption-attachment-4035\" class=\"wp-image-4035 size-medium\" src=\"https:\/\/todaysveterinarypractice.com\/wp-content\/uploads\/sites\/4\/2014\/01\/TT_Figure-1-300x225.jpg\" alt=\"TT_Figure 1\" width=\"300\" height=\"225\" srcset=\"https:\/\/navc.sitepreview.app\/todaysveterinarypractice.com\/wp-content\/uploads\/sites\/4\/2014\/01\/TT_Figure-1-300x225.jpg 300w, https:\/\/navc.sitepreview.app\/todaysveterinarypractice.com\/wp-content\/uploads\/sites\/4\/2014\/01\/TT_Figure-1.jpg 400w\" sizes=\"(max-width: 300px) 100vw, 300px\" \/><\/a><p id=\"caption-attachment-4035\" class=\"wp-caption-text\">Figure 1. A stocked crash cart<\/p><\/div>\n<h3><b>Education &amp; Leadership<\/b><\/h3>\n<p class=\"p1\"><span class=\"s1\">Refresher training every 6 months is also recommended (<strong>I-A<\/strong>).<\/span><span class=\"s2\"><sup>2,3<\/sup><\/span><span class=\"s1\"> The RECOVER authors developed a comprehensive, standardized online CPR course offered through Veritas (veritasdvm.com) and endorsed by the Veterinary Emergency and Critical Care Society and American College of Veterinary Emergency and Critical Care. ALS certification is currently in development. <\/span><\/p>\n<p class=\"p1\"><span class=\"s1\">Specific leadership training for those who may be leading a CPR (<strong>I-A<\/strong>) is recommended; both veterinarians and technicians are capable of leading such a team (<strong>IIb-B<\/strong>).<\/span><span class=\"s2\"><sup>2,3<\/sup><\/span><span class=\"s1\"> Regular debriefing after a CPR event should take place to discuss what went well or wrong (<strong>I-A<\/strong>).<\/span><span class=\"s2\"><sup>2,3<\/sup><\/span><\/p>\n<h3 class=\"p4\"><span class=\"s1\"><b>CPR &amp; Anesthesia<\/b><\/span><\/h3>\n<p class=\"p1\"><span class=\"s1\">Prompt, high quality CPR should be provided for anesthetic-related CPA patients due to their significantly higher survival rate of 47% (<strong>I-B<\/strong>).<\/span><span class=\"s2\"><sup>2,3<\/sup><\/span><span class=\"s1\"> Planning ahead for &#8220;worst case scenario&#8221; situation\u2014by calculating emergency drug dosages and ensuring easy access to emergency equipment\u2014before the anesthetic procedure can shave off precious seconds, allowing more rapid diagnosis of CPA and initiation of CPR.<\/span><\/p>\n<h2 class=\"p3\"><span class=\"s1\"><b>DOMAIN 2: BASIC LIFE SUPPORT<\/b><\/span><\/h2>\n<p class=\"p1\"><span class=\"s1\">The BLS domain focused on the importance of providing high-quality BLS to patients and, therefore, increasing the likelihood of return of spontaneous circulation (ROSC).<\/span><span class=\"s2\"><sup>4<\/sup><\/span><span class=\"s1\"> For the RECOVER guidelines, BLS includes:<\/span><span class=\"s2\"><sup>4<\/sup><\/span><\/p>\n<ul class=\"ul1\">\n<li class=\"li1\"><span class=\"s1\">Recognition of CPA<\/span><\/li>\n<li class=\"li1\"><span class=\"s1\">Chest compressions <\/span><\/li>\n<li class=\"li1\"><span class=\"s1\">Ventilation<\/span><\/li>\n<li class=\"li1\"><span class=\"s1\">Airway management.<\/span><\/li>\n<\/ul>\n<h3 class=\"p4\"><span class=\"s1\"><b>Recognition of CPA<\/b><\/span><\/h3>\n<p class=\"p1\"><span class=\"s1\">If a patient is unresponsive and apneic, CPR should be initiated aggressively and immediately (<strong>I-B<\/strong>); wasting time for confirmation of CPA by pulse palpation or ECG is not recommended (<strong>III-B<\/strong>).<\/span><span class=\"s2\"><sup>2,4,5<\/sup><\/span><\/p>\n<div id=\"attachment_4036\" style=\"width: 310px\" class=\"wp-caption alignnone\"><a href=\"https:\/\/todaysveterinarypractice.com\/wp-content\/uploads\/sites\/4\/2014\/01\/TT_Figure-2.jpg\"><img loading=\"lazy\" decoding=\"async\" aria-describedby=\"caption-attachment-4036\" class=\"wp-image-4036 size-medium\" src=\"https:\/\/todaysveterinarypractice.com\/wp-content\/uploads\/sites\/4\/2014\/01\/TT_Figure-2-300x177.jpg\" alt=\"TT_Figure 2\" width=\"300\" height=\"177\" srcset=\"https:\/\/navc.sitepreview.app\/todaysveterinarypractice.com\/wp-content\/uploads\/sites\/4\/2014\/01\/TT_Figure-2-300x177.jpg 300w, https:\/\/navc.sitepreview.app\/todaysveterinarypractice.com\/wp-content\/uploads\/sites\/4\/2014\/01\/TT_Figure-2.jpg 508w\" sizes=\"(max-width: 300px) 100vw, 300px\" \/><\/a><p id=\"caption-attachment-4036\" class=\"wp-caption-text\">Figure 2. A CPR drill<\/p><\/div>\n<h3 class=\"p4\"><span class=\"s1\"><b>Chest Compressions<\/b><\/span><\/h3>\n<p class=\"p1\"><span class=\"s1\">Chest compressions should be (<b>Figure 2<\/b>):<\/span><\/p>\n<ul class=\"ul1\">\n<li class=\"li1\"><span class=\"s1\">Initiated in lateral recumbency (<strong>I-B<\/strong>) <\/span><\/li>\n<li class=\"li1\"><span class=\"s1\">At a rate of 100 to 120 compressions per minute for both dogs and cats (<strong>I-A<\/strong>)<\/span><\/li>\n<li class=\"li1\"><span class=\"s1\">Performed with chest compression depth being to \u00bd the width of the chest (IIa-A)<\/span><\/li>\n<li class=\"li1\"><span class=\"s1\">Performed without leaning on the patient, allowing for full chest-wall recoil (I-A).<\/span><span class=\"s2\"><sup>2,4<\/sup><\/span><\/li>\n<\/ul>\n<p class=\"p1\"><span class=\"s1\">CPR should be performed without interruption in 2-minute cycles to maximize coronary perfusion (<strong>I-A<\/strong>), with a change in compressor after each cycle in order to minimize fatigue (<strong>I-B<\/strong>).<\/span><span class=\"s2\"><sup>2,4<\/sup><\/span><\/p>\n<h3 class=\"p4\"><span class=\"s1\"><b>Ventilation &amp; Airway Management<\/b><\/span><\/h3>\n<p class=\"p1\"><span class=\"s1\">Regardless of compression technique, simultaneous ventilation should be provided via a cuffed endotracheal tube (with cuff inflated) at a rate of 10 breaths per minute, with a tidal volume of 10 mL\/kg and an inspiratory time of 1 second (<strong>I-A<\/strong>).<\/span><span class=\"s2\"><sup>2,4<\/sup><\/span><\/p>\n<ul class=\"ul1\">\n<li class=\"li1\"><span class=\"s1\">Endotracheal intubation and ventilation should be performed simultaneously during chest compressions in lateral recumbency.<\/span><span class=\"s2\"><sup>2,4<\/sup><\/span><\/li>\n<li class=\"li1\"><span class=\"s1\">A laryngoscope should always be used and tube placement confirmed by visualization (tube passing through the arytenoids), auscultation, observing chest wall movement, and capnometry.<\/span><span class=\"s2\"><sup>2,4<\/sup><\/span><\/li>\n<li class=\"li1\"><span class=\"s1\">Ventilation with 100% oxygen is reasonable (<strong>IIa-B<\/strong>); however, use of room air may also be considered (<strong>IIb-B<\/strong>).<\/span><span class=\"s2\"><sup>2,4<\/sup><\/span><\/li>\n<\/ul>\n<p class=\"p1\"><span class=\"s1\">In single-rescuer CPR, or if endotracheal intubation is unavailable, mouth-to-snout ventilation is recommended, with 2 breaths delivered after every 30 compressions (<strong>I-B<\/strong>).<\/span><span class=\"s2\"><sup>2,4<\/sup><\/span><span class=\"s1\"> On the other hand, if sufficient trained personnel are available, interposed abdominal compressions may increase venous return and should be considered (<strong>IIa-B<\/strong>).<\/span><span class=\"s2\"><sup>2,4<\/sup><\/span><\/p>\n<div class=\"orange-box\">\n<p class=\"p1\"><span class=\"s3\"><b>Specific hand placement for CPR<\/b><\/span><span class=\"s1\"> depends on patient size and breed:<\/span><span class=\"s2\"><sup><span style=\"font-size: small\">2,4<\/span><\/sup><\/span><\/p>\n<ul class=\"ul1\">\n<li class=\"li1\"><b><\/b><span class=\"s1\"><b>Larger dogs<\/b> benefit from compressions over the widest portion of the thorax, using the thoracic pump theory (IIa-C) (<b>Figure 3<\/b>).<\/span><\/li>\n<li class=\"li1\"><b><\/b><span class=\"s1\"><b>Barrel-chested breeds<\/b>, such as bulldogs, may benefit from sternal chest compressions in dorsal recumbency (IIb-C).<\/span><\/li>\n<li class=\"li1\"><b><\/b><span class=\"s1\"><b>Smaller dogs, keel-chested dogs, and cats<\/b> may benefit from compressions directly over the heart, employing the cardiac pump theory (IIa-C) (<b>Figure 4<\/b>).<\/span><\/li>\n<li class=\"li1\"><b><\/b><span class=\"s1\"><b>Smaller dogs and cats<\/b> also benefit from circumferential compressions (IIb-C), although benefits are less clear.<\/span><\/li>\n<\/ul>\n<div id=\"attachment_4037\" style=\"width: 235px\" class=\"wp-caption alignnone\"><a href=\"https:\/\/todaysveterinarypractice.com\/wp-content\/uploads\/sites\/4\/2014\/01\/TT_Figure-3.jpg\"><img loading=\"lazy\" decoding=\"async\" aria-describedby=\"caption-attachment-4037\" class=\"wp-image-4037 size-medium\" src=\"https:\/\/todaysveterinarypractice.com\/wp-content\/uploads\/sites\/4\/2014\/01\/TT_Figure-3-225x300.jpg\" alt=\"TT_Figure 3\" width=\"225\" height=\"300\" \/><\/a><p id=\"caption-attachment-4037\" class=\"wp-caption-text\">Figure 3. Large dog hand placement (thoracic pump theory)<\/p><\/div>\n<p class=\"p1\"><span class=\"s1\">\u00a0<\/span><\/p>\n<div id=\"attachment_4038\" style=\"width: 310px\" class=\"wp-caption alignnone\"><a href=\"https:\/\/todaysveterinarypractice.com\/wp-content\/uploads\/sites\/4\/2014\/01\/TT_Figure-4.jpg\"><img loading=\"lazy\" decoding=\"async\" aria-describedby=\"caption-attachment-4038\" class=\"wp-image-4038 size-medium\" src=\"https:\/\/todaysveterinarypractice.com\/wp-content\/uploads\/sites\/4\/2014\/01\/TT_Figure-4-300x225.jpg\" alt=\"TT_Figure 4\" width=\"300\" height=\"225\" srcset=\"https:\/\/navc.sitepreview.app\/todaysveterinarypractice.com\/wp-content\/uploads\/sites\/4\/2014\/01\/TT_Figure-4-300x225.jpg 300w, https:\/\/navc.sitepreview.app\/todaysveterinarypractice.com\/wp-content\/uploads\/sites\/4\/2014\/01\/TT_Figure-4.jpg 400w\" sizes=\"(max-width: 300px) 100vw, 300px\" \/><\/a><p id=\"caption-attachment-4038\" class=\"wp-caption-text\">Figure 4. Small dog\/Cat hand placement (cardiac pump theory)<\/p><\/div>\n<\/div>\n<h2 class=\"p1\"><b>DOMAIN 3: ADVANCED LIFE SUPPORT<\/b><\/h2>\n<p class=\"p1\"><span class=\"s1\">The ALS domain provides a larger number of recommendations due to the greater number of interventions that may be required.<\/span><span class=\"s2\"><sup>6<\/sup><\/span><span class=\"s1\"> The main tenets of the ALS recommendations pertain to:<\/span><span class=\"s2\"><sup>6<\/sup><\/span><\/p>\n<ul class=\"ul1\">\n<li class=\"li1\"><span class=\"s1\">Vasopressor therapy<\/span><\/li>\n<li class=\"li1\"><span class=\"s1\">Vagolytic therapy<\/span><\/li>\n<li class=\"li1\"><span class=\"s1\">Electrical cardioversion<\/span><\/li>\n<li class=\"li1\"><span class=\"s1\">Correction or reversal of condition(s) that led to arrest.<\/span><\/li>\n<\/ul>\n<h3 class=\"p4\"><span class=\"s1\"><b>Vasopressor Therapy<\/b><\/span><\/h3>\n<p class=\"p1\"><span class=\"s1\">Vasopressor therapy is directed at increasing systemic vascular resistance in an effort to increase coronary and cerebral blood flow.<\/span><span class=\"s2\"><sup>6<\/sup><\/span><span class=\"s1\"> Epinephrine, a nonselective adrenergic agonist, is the most commonly used vasopressor for CPR therapy; it affects both alpha and beta adrenergic receptors. Alpha adrenergic stimulation causes peripheral vasoconstriction. Beta adrenergic stimulation has positive inotropic and chronotropic effects, which increase myocardial oxygen demand and, therefore, may be detrimental in CPA patients.<\/span><span class=\"s2\"><sup>6<\/sup><\/span><\/p>\n<p class=\"p1\"><span class=\"s1\"><b><i>Epinephrine<\/i><\/b><\/span><\/p>\n<ul class=\"ul1\">\n<li class=\"li1\"><span class=\"s1\">Low-dose epinephrine (<strong>0.01 mg\/kg<\/strong>) is recommended for routine use every other BLS cycle (<strong>I-B<\/strong>) or every 3 to 5 minutes.<\/span><span class=\"s2\"><sup>2,6<\/sup><\/span><\/li>\n<li class=\"li1\"><span class=\"s1\">High-dose epinephrine (<strong>0.1 mg\/kg<\/strong>) may be considered after prolonged CPR (<strong>IIb-B<\/strong>).<\/span><\/li>\n<\/ul>\n<p class=\"p1\"><span class=\"s1\">Experimental data in dogs demonstrated <em>no benefit or reduced survival<\/em> with use of high-dose epinephrine.<\/span><span class=\"s2\"><sup>2,6<\/sup><\/span><span class=\"s1\"> Additionally, some research argues that high-dose epinephrine may resuscitate patients with irreversible, ischemic damage, which leads to ethical questions regarding use of high-dose epinephrine.<\/span><span class=\"s2\"><sup>6<\/sup><\/span><\/p>\n<p class=\"p1\"><span class=\"s1\"><b><i>Vasopressin<\/i><\/b><\/span><\/p>\n<p class=\"p1\"><span class=\"s1\">Unlike epinephrine, vasopressin does not affect heart rate or contractility and, therefore, does not increase myocardial oxygen demand. Vasopressin (<strong>0.8 U\/kg<\/strong>) may be considered as a substitute or in combination with epinephrine (<strong>IIb-B<\/strong>) per the RECOVER guidelines.<\/span><span class=\"s2\"><sup>2,6<\/sup><\/span><span class=\"s1\"> While vasopressin is advocated for use in CPR,<\/span><span class=\"s2\"><sup>2,6<\/sup><\/span><span class=\"s1\"> research regarding its benefits is mixed. The only prospective veterinary study showed no benefit over epinephrine use.<\/span><span class=\"s2\"><sup>6-7<\/sup><\/span><\/p>\n<h3 class=\"p4\"><span class=\"s1\"><b>Vagolytic Therapy<\/b><\/span><\/h3>\n<p class=\"p1\"><span class=\"s1\">During CPR, vagolytic therapy is usually provided by atropine.<\/span><span class=\"s2\"><sup>6<\/sup><\/span><span class=\"s1\"> Limited data is available on atropine use in CPR, with no high-quality data available for dogs or cats.<\/span><span class=\"s2\"><sup>6<\/sup><\/span><\/p>\n<p class=\"p1\"><span class=\"s1\">Current best-evidence suggests that:<\/span><\/p>\n<ul class=\"ul1\">\n<li class=\"li1\"><span class=\"s1\">Atropine can be used in patients with CPA related to increased vagal tone and associated asystole or pulseless electrical activity (<strong>IIb-B<\/strong>). <\/span><\/li>\n<li class=\"li1\"><span class=\"s1\">Routine use of atropine may be considered (<strong>IIb-C<\/strong>).<\/span><span class=\"s2\"><sup>2,6<\/sup><\/span><\/li>\n<li class=\"li1\"><span class=\"s1\">In experimental studies in dogs, high-dose atropine is associated with poor outcomes; therefore, <strong>doses above 0.04 mg\/kg should be avoided<\/strong>.<\/span><span class=\"s2\"><sup>6<\/sup><\/span><\/li>\n<\/ul>\n<h3><b>Electrical Cardioversion<\/b><\/h3>\n<p class=\"p1\"><span class=\"s1\">Electrical defibrillation is indicated in patients suffering from ventricular fibrillation (VF) (<b>Figure 5<\/b>) or pulseless ventricular tachycardia (VT), and has been shown to significantly improve ROSC in these patients.<\/span><span class=\"s2\"><sup>6<\/sup><\/span><\/p>\n<div id=\"attachment_4039\" style=\"width: 310px\" class=\"wp-caption alignnone\"><a href=\"https:\/\/todaysveterinarypractice.com\/wp-content\/uploads\/sites\/4\/2014\/01\/TT_Figure-5.jpg\"><img loading=\"lazy\" decoding=\"async\" aria-describedby=\"caption-attachment-4039\" class=\"wp-image-4039 size-medium\" src=\"https:\/\/todaysveterinarypractice.com\/wp-content\/uploads\/sites\/4\/2014\/01\/TT_Figure-5-300x226.jpg\" alt=\"TT_Figure 5\" width=\"300\" height=\"226\" srcset=\"https:\/\/navc.sitepreview.app\/todaysveterinarypractice.com\/wp-content\/uploads\/sites\/4\/2014\/01\/TT_Figure-5-300x226.jpg 300w, https:\/\/navc.sitepreview.app\/todaysveterinarypractice.com\/wp-content\/uploads\/sites\/4\/2014\/01\/TT_Figure-5.jpg 398w\" sizes=\"(max-width: 300px) 100vw, 300px\" \/><\/a><p id=\"caption-attachment-4039\" class=\"wp-caption-text\">Figure 5. Ventricular fibrillation<\/p><\/div>\n<p class=\"p1\"><span class=\"s1\">\u00a0<\/span><span class=\"s1\">RECOVER guidelines recommend:<\/span><\/p>\n<ul class=\"ul1\">\n<li class=\"li1\"><span class=\"s1\"><em>Use of a biphasic defibrillator<\/em> (<strong>I-A<\/strong>) has been shown to be more effective than monophasic current<\/span><span class=\"s2\"><sup>2,6<\/sup><\/span><\/li>\n<li class=\"li1\"><span class=\"s1\"><em>Single-shock therapy<\/em> versus stacked-shock therapy in order to minimize interruption of chest compressions (<strong>I-B<\/strong>) (However, evidence on stacked shocks versus single shocks in dogs and cats is lacking.<\/span><span class=\"s2\"><sup>2,6<\/sup><\/span><span class=\"s1\">) <\/span><\/li>\n<li class=\"li1\"><span class=\"s1\"><em>Immediate defibrillation<\/em> for pulseless VT\/VF of less than 4 minutes duration as there is minimal ischemia during this time (<strong>I-B<\/strong>)<\/span><span class=\"s2\"><sup>2,6<\/sup><\/span><\/li>\n<li class=\"li1\"><span class=\"s1\"><em>Two-minute BLS cycle before defibrillation<\/em> for pulseless VT\/VF of greater than 4 minutes duration in order to maximize coronary perfusion (<strong>I-B<\/strong>)<\/span><span class=\"s2\"><sup>2,6<\/sup><\/span><\/li>\n<li class=\"li1\"><span class=\"s1\"><em>Immediate defibrillation<\/em> may be considered if VF or pulseless VT is diagnosed during an intercycle pause (<strong>IIb-B<\/strong>).<\/span><span class=\"s2\"><sup>2,6<\/sup><\/span><\/li>\n<\/ul>\n<p class=\"p1\"><span class=\"s1\">If defibrillation is unsuccessful, escalation of defibrillation energy is reasonable <strong>(IIa-B<\/strong>).<\/span><span class=\"s2\"><sup>2,6<\/sup><\/span><span class=\"s1\"> Readers with electrical defibrillators should view the RECOVER drug dosage chart specific to their defibrillator type for recommendations on energy selection (see veccs.org).<\/span><span class=\"s2\"><sup>2<\/sup><\/span><\/p>\n<h3 class=\"p1\"><span class=\"s1\"><b>Additional ALS Therapies<\/b><\/span><\/h3>\n<p class=\"p1\"><span class=\"s1\"><b><i>Medications<\/i><\/b><\/span><\/p>\n<p class=\"p1\"><span class=\"s1\">Routine use of IV fluids, magnesium, corticosteroids, or calcium is not recommended (<strong>III-B, IIb-B, III-C, III-B,<\/strong> respectively), but these drugs may be beneficial in specific patient populations.<\/span><span class=\"s2\"><sup>2,6<\/sup><\/span><span class=\"s1\"> Use of these drugs, as well as amiodarone, lidocaine, sodium bicarbonate, reversal agents, and impedance threshold devices are thoroughly covered in the RECOVER guidelines.<\/span><span class=\"s2\"><sup>2,6<\/sup><\/span><\/p>\n<p class=\"p1\"><span class=\"s1\">Of note, naloxone should be administered to CPA patients with suspected opioid toxicity (<strong>I-B<\/strong>), and may be considered in all patients that recently received opioids (<strong>IIb-B<\/strong>).<\/span><span class=\"s2\"><sup>2,6<\/sup><\/span><span class=\"s1\"> If IV access is unavailable, intraosseous access is obtained; if intraosseous access is unavailable, intratracheal administration may be performed (<strong>IIb-B<\/strong>) (see <b>Intratracheal Administration &amp; Drugs<\/b>).<\/span><span class=\"s2\"><sup>2,6<\/sup><\/span><\/p>\n<p class=\"p1\"><span class=\"s1\"><b><i>Procedures<\/i><\/b><\/span><\/p>\n<p class=\"p1\"><span class=\"s1\">Open-chest CPR may be considered in cases of intrathoracic disease if appropriate resources are available for the intensive PCA care these patients will require (<strong>IIb-C<\/strong>).<\/span><span class=\"s2\"><sup>2,6<\/sup><\/span><\/p>\n<div class=\"orange-box\">\n<h3 class=\"p3\"><span class=\"s1\"><b>Intratracheal Administration &amp; Drugs<\/b><\/span><\/h3>\n<p class=\"p1\"><span class=\"s1\">When administering drugs via the intratracheal route, dilution with normal saline and use of a long catheter, such as a red-rubber catheter placed through the endotracheal tube to the level of the carina, are recommended (<strong>I-B<\/strong>).<\/span><span class=\"s2\"><sup><span style=\"font-size: small\">2,6,8<\/span><\/sup><\/span><\/p>\n<p class=\"p1\"><span class=\"s1\">Use the mnemonic <\/span><span class=\"s4\"><b>NAVEL<\/b><\/span><span class=\"s1\"> to remember which drugs can be administered intratracheally:<\/span><span class=\"s2\"><sup><span style=\"font-size: small\">8<\/span><\/sup><\/span><\/p>\n<p class=\"p6\"><span class=\"s1\"><strong>N<\/strong>aloxone <strong>A<\/strong>tropine <strong>V<\/strong>asopressin <strong>E<\/strong>pinephrine <strong>L<\/strong>idocaine<\/span><\/p>\n<\/div>\n<h2 class=\"p3\"><span class=\"s1\"><b>DOMAIN 4: CPR MONITORING<\/b><\/span><\/h2>\n<p class=\"p1\"><span class=\"s1\">Proper monitoring plays a critical role in patients at risk for, suffering from, or recovering from CPA. Monitoring involves understanding the monitor&#8217;s limitations, and correctly interpreting the information obtained. Monitoring is further subdivided into:<\/span><span class=\"s2\"><sup>5<\/sup><\/span><\/p>\n<ul>\n<li class=\"p1\"><span class=\"s1\">Diagnosing CPA and confirmation of endotracheal intubation<\/span><\/li>\n<li class=\"p1\"><span class=\"s1\">Monitoring during CPR<\/span><\/li>\n<li class=\"p1\"><span class=\"s1\">PCA monitoring.<\/span><\/li>\n<\/ul>\n<h3 class=\"p4\"><span class=\"s1\"><b>Diagnosing CPA<\/b><\/span><\/h3>\n<p class=\"p1\"><span class=\"s1\">Rapid identification of a patient requiring CPR allows more rapid institution of BLS and ALS, which increases the chance of ROSC.<\/span><\/p>\n<p class=\"p1\"><span class=\"s1\"><b><i>Pulse Palpation<\/i><\/b><\/span><\/p>\n<p class=\"p1\"><span class=\"s1\">Pulse palpation to diagnose CPA in unresponsive, apneic patients is not recommended (<strong>III-B<\/strong>) given that:<\/span><span class=\"s2\"><sup>2,5<\/sup><\/span><\/p>\n<ul class=\"ul1\">\n<li class=\"li1\"><span class=\"s1\">Lack of a palpable pulse does not always indicate CPA<\/span><\/li>\n<li class=\"li1\"><span class=\"s1\">Length of time it takes to determine if a patient is pulseless can delay initiation of CPR.<\/span><\/li>\n<\/ul>\n<p class=\"p1\"><span class=\"s1\">Human research has shown that diagnosis of CPA by pulse palpation is not reliable, with only 2% of professionals diagnosing a pulseless patient in less than 10 seconds.<\/span><span class=\"s2\"><sup>5<\/sup><\/span><span class=\"s1\"> For this reason, current human guidelines limit pulse palpation by health care professionals to less than 10 seconds before BLS measures are initiated.<\/span><span class=\"s2\"><sup>5<\/sup><\/span><\/p>\n<p class=\"p1\"><span class=\"s1\"><b><i>Electrocardiography &amp; Blood Pressure Measurement<\/i><\/b><\/span><\/p>\n<p class=\"p1\"><span class=\"s1\">Electrocardiography (ECG) or Doppler blood pressure measurement to diagnose CPA in unresponsive, apneic patients is not recommended (<strong>III-C<\/strong>) due to the reasons listed above for pulse palpation.<\/span><span class=\"s2\"><sup>2,5<\/sup><\/span><\/p>\n<p class=\"p1\"><span class=\"s1\">However, ECG or Doppler blood pressure measurement to detect impending CPA is reasonable to perform in at-risk patients (<strong>IIa-C<\/strong>) (<b>Figure 6<\/b>). Evidence of an ECG rhythm does not always indicate a perfusing rhythm; absence of a Doppler signal does not always indicate CPA.<\/span><span class=\"s2\"><sup>2,5<\/sup><\/span><\/p>\n<p class=\"p1\"><span class=\"s1\">In patients with VF, waveform analysis may provide prognostic information, with coarse VF (high amplitude) associated with better outcomes than fine VF (low amplitude) (<strong>IIb-B<\/strong>).<\/span><span class=\"s2\"><sup>2,5<\/sup><\/span><\/p>\n<div id=\"attachment_4040\" style=\"width: 310px\" class=\"wp-caption alignnone\"><a href=\"https:\/\/todaysveterinarypractice.com\/wp-content\/uploads\/sites\/4\/2014\/01\/TT_Figure-6.jpg\"><img loading=\"lazy\" decoding=\"async\" aria-describedby=\"caption-attachment-4040\" class=\"wp-image-4040 size-medium\" src=\"https:\/\/todaysveterinarypractice.com\/wp-content\/uploads\/sites\/4\/2014\/01\/TT_Figure-6-300x201.jpg\" alt=\"TT_Figure 6\" width=\"300\" height=\"201\" srcset=\"https:\/\/navc.sitepreview.app\/todaysveterinarypractice.com\/wp-content\/uploads\/sites\/4\/2014\/01\/TT_Figure-6-300x201.jpg 300w, https:\/\/navc.sitepreview.app\/todaysveterinarypractice.com\/wp-content\/uploads\/sites\/4\/2014\/01\/TT_Figure-6.jpg 448w\" sizes=\"(max-width: 300px) 100vw, 300px\" \/><\/a><p id=\"caption-attachment-4040\" class=\"wp-caption-text\">Figure 6. PCA Monitoring<\/p><\/div>\n<p class=\"p1\"><span class=\"s1\"><b><i>End-Tidal Carbon Dioxide Monitoring<\/i><\/b><\/span><\/p>\n<p class=\"p1\"><span class=\"s1\">End-tidal carbon dioxide (EtCO2) monitoring is recommended for intubated patients at risk of CPA (<strong>I-A<\/strong>).<\/span><span class=\"s2\"><sup>2,5<\/sup><\/span><span class=\"s1\"> EtCO2 correlates well with cardiac output and rapidly drops to zero at CPA onset.<\/span><span class=\"s2\"><sup>5,9<\/sup><\/span><span class=\"s1\"> Additional reasons for rapid decreases include:<\/span><span class=\"s2\"><sup>9<\/sup><\/span><\/p>\n<ul class=\"ul1\">\n<li class=\"li1\"><span class=\"s1\">Leaking anesthetic circuit <\/span><\/li>\n<li class=\"li1\"><span class=\"s1\">Airway obstruction <\/span><\/li>\n<li class=\"li1\"><span class=\"s1\">Massive pulmonary thromboembolism <\/span><\/li>\n<li class=\"li1\"><span class=\"s1\">Severe hypotension (may indicate impending CPA).<\/span><\/li>\n<\/ul>\n<p class=\"p1\"><span class=\"s1\">EtCO<sub>2<\/sub> readings should be interpreted cautiously and in conjunction with other monitoring parameters. Additionally, many arrests in dogs and cats are asphyxial in nature (due to respiratory failure, hypoxemia, or hypercarbia), which may cause elevated EtCO2 readings immediately following endotracheal intubation and manual ventilation.<\/span><span class=\"s2\"><sup>2,5<\/sup><\/span><\/p>\n<ul class=\"ul1\">\n<li class=\"li1\"><span class=\"s1\">Therefore, immediate post-intubation EtCO<sub>2<\/sub> readings should not be used to diagnose CPA because elevated values may lead to the incorrect conclusion that the patient is not in CPA (<strong>III-B<\/strong>).<\/span><span class=\"s2\"><sup>2,5<\/sup><\/span><\/li>\n<li class=\"li1\"><span class=\"s1\">Similarly, an EtCO<sub>2<\/sub> reading may not be obtained (or a reading of zero may be obtained) immediately following endotracheal intubation in a patient suffering from CPA.<sup>5<\/sup><\/span><\/li>\n<\/ul>\n<h3 class=\"p4\"><span class=\"s1\"><b>Confirmation of Endotracheal Intubation<\/b><\/span><\/h3>\n<p class=\"p1\"><span class=\"s1\">For the reasons stated above, use of EtCO2 alone to verify endotracheal intubation is not recommended (<strong>III-B<\/strong>).<\/span><span class=\"s2\"><sup>2,5<\/sup><\/span><span class=\"s1\"> Verification should be accomplished by <strong>all<\/strong> 3 of the following (<strong>IIa-B<\/strong>):<\/span><span class=\"s2\"><sup>2,5<\/sup><\/span><\/p>\n<ul class=\"ul1\">\n<li class=\"li1\"><span class=\"s1\">Laryngoscopy <\/span><\/li>\n<li class=\"li1\"><span class=\"s1\">Bilateral lung sounds and chest movement<\/span><\/li>\n<li class=\"li1\"><span class=\"s1\">EtCO2 readings.<\/span><\/li>\n<\/ul>\n<h3 class=\"p4\"><span class=\"s1\"><b>Monitoring during CPR<\/b><\/span><\/h3>\n<p class=\"p1\"><span class=\"s1\"><b><i>Electrocardiography<\/i><\/b><\/span><\/p>\n<p class=\"p1\"><span class=\"s1\">ECG use during CPR is recommended for rhythm evaluation, but should (<strong>I-C<\/strong>):<\/span><span class=\"s2\"><sup>2,5<\/sup><\/span><\/p>\n<ul class=\"ul1\">\n<li class=\"li1\"><span class=\"s1\">Only be evaluated during intercycle pauses <\/span><\/li>\n<li class=\"li1\"><span class=\"s1\"><strong>Not<\/strong> delay resumption of chest compressions.<\/span><\/li>\n<\/ul>\n<p class=\"p1\"><span class=\"s1\"><b><i>End-Tidal Carbon Dioxide Monitoring<\/i><\/b><\/span><\/p>\n<p class=\"p1\"><span class=\"s1\">Since EtCO<sub>2<\/sub> correlates well with cardiac output, EtCO<sub>2<\/sub> monitoring during CPR to evaluate efficacy of chest compressions is reasonable if minute ventilation is held constant (<strong>IIa-B<\/strong>).<\/span><span class=\"s2\"><sup>2,5,9<\/sup><\/span><span class=\"s1\"> Additionally, ROSC will cause a sharp increase in EtCO<sub>2<\/sub>, and EtCO<sub>2<\/sub> monitoring should be used as an indicator of ROSC during CPR (<strong>I-A<\/strong>).<\/span><span class=\"s2\"><sup>2,5,9<\/sup><\/span><\/p>\n<p class=\"p1\"><span class=\"s1\"><b><i>Blood Gas &amp; Electrolyte Analysis<\/i><\/b><\/span><\/p>\n<p class=\"p1\"><span class=\"s1\">Blood gas and electrolyte analysis may be helpful in evaluating CPR effectiveness and identifying underlying causes.<\/span><span class=\"s2\"><sup>5<\/sup><\/span><\/p>\n<ul class=\"ul1\">\n<li class=\"li1\"><span class=\"s1\">Mixed-venous or central-venous blood gas analysis may more accurately reflect tissue acid\u2013base status during CPA; use of such values to evaluate CPR effectiveness may be considered (<strong>IIb-B<\/strong>).<\/span><span class=\"s2\"><sup>2,5<\/sup><\/span><span class=\"s1\"> Increased PCO<sub>2<\/sub>, increasing lactate, or decreasing pH may indicate inadequate compression or ventilation technique; a change in technique should be considered. <\/span><\/li>\n<li class=\"li1\"><span class=\"s1\">Because CPA causes poor peripheral perfusion, peripheral venous or arterial blood gas analysis is not recommended to evaluate CPR effectiveness (<strong>III-A<\/strong>).<\/span><span class=\"s2\"><sup>2,5<\/sup><\/span><\/li>\n<\/ul>\n<p class=\"p1\"><span class=\"s1\">CPA may be caused by significant electrolyte derangements.<\/span><span class=\"s2\"><sup>2,5,6<\/sup><\/span><span class=\"s1\"> If underlying electrolyte derangements are suspected or known, electrolyte analysis to guide therapy is recommended (<strong>I-C<\/strong>) and electrolyte monitoring during CPR may be considered in all patients (<strong>IIb-B<\/strong>).<\/span><span class=\"s2\"><sup>2,5<\/sup><\/span><\/p>\n<ul class=\"ul1\">\n<li class=\"li1\"><span class=\"s1\">In patients with documented hyperkalemia, treatment is recommended <strong>(I-B<\/strong>).<\/span><span class=\"s2\"><sup>2,6<\/sup><\/span><\/li>\n<li class=\"li1\"><span class=\"s1\">Treatment of documented hypokalemia may be considered but clear benefit has not been shown (<strong>IIb-C<\/strong>).<\/span><span class=\"s2\"><sup>2,6<\/sup><\/span><\/li>\n<\/ul>\n<p class=\"p1\"><span class=\"s1\"><b><i>Real-Time CPR Feedback<\/i><\/b><\/span><\/p>\n<p class=\"p1\"><span class=\"s1\">While widely used in human medicine but not in veterinary medicine, real-time CPR feedback devices that improve CPR effectiveness may be useful in veterinary CPR (<strong>IIa-C<\/strong>).<\/span><span class=\"s2\"><sup>2<\/sup><\/span><\/p>\n<h3 class=\"p4\"><span class=\"s1\"><b>PCA Monitoring<\/b><\/span><\/h3>\n<p class=\"p1\"><span class=\"s1\">While limited data is available regarding PCA monitoring, the RECOVER authors recommend use of monitoring appropriate for a critically-ill patient.<\/span><span class=\"s2\"><sup>2,5<\/sup><\/span><span class=\"s1\"> This monitoring should detect impending recurrence of CPA as well as guide therapy to avoid its recurrence (<strong>I-C<\/strong>).<\/span><span class=\"s2\"><sup>2,5<\/sup><\/span><\/p>\n<p class=\"p1\"><span class=\"s1\">Mimimum monitoring should consist of <strong>(I-B<\/strong>):<\/span><span class=\"s2\"><sup>2,5<\/sup><\/span><\/p>\n<ul class=\"ul1\">\n<li class=\"li1\"><span class=\"s1\">Continuous ECG<\/span><\/li>\n<li class=\"li1\"><span class=\"s1\">Arterial blood pressure measurement<\/span><\/li>\n<li class=\"li1\"><span class=\"s1\">Body temperature<\/span><\/li>\n<li class=\"li1\"><span class=\"s1\">Oxygenation\/ventilation status.<\/span><\/li>\n<\/ul>\n<p class=\"p1\"><span class=\"s1\">Additional clinicopathologic monitoring, which is dependent on patient comorbidities, may include blood glucose and lactate concentrations, although the benefit of monitoring these parameters in all PCA patients is not clear (<strong>IIb-B<\/strong>).<\/span><span class=\"s2\"><sup>2,5<\/sup><\/span><\/p>\n<h2 class=\"p3\"><span class=\"s1\"><b>DOMAIN 5: POST CARDIAC ARREST CARE<\/b><\/span><\/h2>\n<p class=\"p1\"><span class=\"s1\">Excellent PCA care is required to minimize the likelihood of CPA recurrence and maximize the chance of a patient returning home with its owners. One study showed that over 50% of dogs and cats will suffer another CPA event while in the hospital, which correlates with human data on the subject.<\/span><span class=\"s2\"><sup>5<\/sup><\/span><\/p>\n<p class=\"p1\"><span class=\"s1\">Patients with CPA who experience ROSC are likely to have:<\/span><span class=\"s2\"><sup>10,11<\/sup><\/span><\/p>\n<ul class=\"ul1\">\n<li class=\"li1\"><span class=\"s1\">Some degree of hemodynamic instability related to vasopressor therapy during CPR or the underlying cause of CPA<\/span><\/li>\n<li class=\"li1\"><span class=\"s1\">Cardiac ischemia<\/span><\/li>\n<li class=\"li1\"><span class=\"s1\">Systemic inflammatory response syndrome (hallmarked by inflammatory system activation and excess circulating cytokines)<\/span><\/li>\n<li class=\"li1\"><span class=\"s1\">Anoxic brain injury.<\/span><\/li>\n<\/ul>\n<h3 class=\"p4\"><span class=\"s1\"><b>Fluid Therapy<\/b><\/span><\/h3>\n<p class=\"p1\"><span class=\"s1\">When titrating IV fluids and vasopressors, the <strong>primary endpoints<\/strong> of central venous oxygen saturation (&gt; 70%) and lactate (&lt; 2.5 mmol\/L) coupled with the following <strong>secondary endpoints<\/strong> may be considered (<strong>IIb-B<\/strong>):<\/span><span class=\"s2\"><sup>2,10,11<\/sup><\/span><\/p>\n<ul class=\"ul1\">\n<li class=\"li1\"><span class=\"s1\">Arterial blood pressure (systolic, 100\u2013200 mm Hg; mean arterial pressure, 80\u2013120 mm Hg)<\/span><\/li>\n<li class=\"li1\"><span class=\"s1\">Central venous pressure (10 cm H2O)<\/span><\/li>\n<li class=\"li1\"><span class=\"s1\">Packed cell volume (&gt; 25%) <\/span><\/li>\n<li class=\"li1\"><span class=\"s1\">Arterial oxygen saturation (SpO2 94\u201398%; PaO2, 80\u2013100 mm Hg).<\/span><\/li>\n<\/ul>\n<p class=\"p1\"><span class=\"s1\">However, routine large-volume IV fluid administration is not recommended unless hypovolemia is strongly suspected or documented (<strong>III-C<\/strong>).<\/span><span class=\"s2\"><sup>2,10<\/sup><\/span><\/p>\n<p><span class=\"s1\"><b>Oxygen Supplementation<\/b><\/span><\/p>\n<p class=\"p1\"><span class=\"s1\">Oxygen supplementation should be titrated to produce normoxia (PaO<sub>2<\/sub>, 80\u2013100 mmHg, or SpO<sub>2<\/sub>, 94%\u201398%), but hyperoxia should be avoided (<strong>I-A<\/strong>).<\/span><span class=\"s2\"><sup>2,10<\/sup><\/span><span class=\"s1\"> While routine, mechanical ventilation of all PCA patients is not recommended (<strong>III-B<\/strong>), mechanical ventilation of hypoventilating CPA patients is reasonable (<strong>IIa-C<\/strong>).<\/span><span class=\"s2\"><sup>2,10<\/sup><\/span><\/p>\n<h3 class=\"p7\"><span class=\"s1\"><b>Referral to Specialty Center<\/b><\/span><\/h3>\n<p class=\"p1\"><span class=\"s1\">Several human studies demonstrate improved survival of patients treated by highly-trained professionals with experience in PCA care and in facilities with higher staff-to-patient ratios.<\/span><span class=\"s2\"><sup>10<\/sup><\/span><\/p>\n<p class=\"p1\"><span class=\"s1\">Veterinary research on the subject is lacking; however, research has indicated that patients were more likely to survive when drugs, such as dopamine and vasopressin, were available and more staff were involved in resuscitation efforts.<\/span><span class=\"s2\"><sup>10<\/sup><\/span><\/p>\n<p class=\"p1\"><span class=\"s1\">For these reasons, it is reasonable to refer a PCA patient to a facility with (<strong>IIa-B<\/strong>):<\/span><span class=\"s2\"><sup>2,10<\/sup><\/span><\/p>\n<ul class=\"ul1\">\n<li class=\"li1\"><span class=\"s1\">24-hour care<\/span><\/li>\n<li class=\"li1\"><span class=\"s1\">Higher staff-to-patient ratios<\/span><\/li>\n<li class=\"li1\"><span class=\"s1\">Advanced critical care capabilities.<\/span><\/li>\n<\/ul>\n<p class=\"p1\"><span class=\"s1\">Many facilities have critical care transportation available. Contact your local emergency\/referral center for critical care transportation options.<\/span><\/p>\n<h3 class=\"p4\"><span class=\"s1\"><b>Other Recommendations<\/b><\/span><\/h3>\n<p class=\"p1\"><span class=\"s1\">The RECOVER guidelines outline several other recommendations for PCA care, including:<\/span><span class=\"s2\"><sup>2,10<\/sup><\/span><\/p>\n<ul class=\"ul1\">\n<li class=\"li1\"><span class=\"s1\">Therapeutic hypothermia<\/span><\/li>\n<li class=\"li1\"><span class=\"s1\">PCA hypertension<\/span><\/li>\n<li class=\"li1\"><span class=\"s1\">Corticosteroids<\/span><\/li>\n<li class=\"li1\"><span class=\"s1\">Seizure prophylaxis <\/span><\/li>\n<li class=\"li1\"><span class=\"s1\">Osmotic agents.<\/span><\/li>\n<\/ul>\n<p class=\"p1\"><span class=\"s1\">See <b>Read the RECOVER Guidelines<\/b> to access more information on these recommendations.<\/span><\/p>\n<div class=\"orange-box\">\n<p class=\"p3\"><span class=\"s1\"><b>Early Goal Directed Therapy<\/b><\/span><\/p>\n<p class=\"p1\"><span class=\"s1\">Most PCA care recommended by the RECOVER initiative pertains to early goal-directed therapy (EGDT).<\/span><span class=\"s2\"><sup><span style=\"font-size: small\">3,10<\/span><\/sup><\/span><span class=\"s1\"> It has been shown to improve outcomes in human patients, though veterinary data on the subject is lacking.<\/span><span class=\"s2\"><sup><span style=\"font-size: small\">10,11<\/span><\/sup><\/span><\/p>\n<p class=\"p1\"><span class=\"s1\">EGDT is directed at:<\/span><\/p>\n<ul>\n<li><span class=\"s1\">Optimizing hemodynamics to maximize perfusion to organs <\/span><\/li>\n<li><span class=\"s1\">Minimizing the likelihood of multiple-organ dysfunction syndrome.<\/span><\/li>\n<\/ul>\n<\/div>\n<h2 class=\"p3\"><span class=\"s1\"><b>IN SUMMARY<\/b><\/span><\/h2>\n<p class=\"p1\"><span class=\"s1\">The RECOVER initiative created the first consensus guidelines on veterinary resuscitation, which provide an in-depth look at the available evidence on veterinary resuscitation.<\/span><span class=\"s2\"><sup>2<\/sup><\/span><span class=\"s1\"> Readers are encouraged to review these guidelines in their entirety as well as seek standardized training in the area of veterinary resuscitation. These consensus guidelines combined with standardized training allow veterinary professionals to provide the best standard of care for CPA patients.<\/span><\/p>\n<h2 class=\"p1\"><span class=\"s1\"><b>FIGURE CREDITS<\/b><\/span><\/h2>\n<p class=\"p1\"><span class=\"s1\">Figures 2 through 4 courtesy David Liss, AS, BA, RVT, VTS (Emergency Critical Care &amp; Small Animal Internal Medicine), CVPM<\/span><\/p>\n<p class=\"p1\"><span class=\"s1\">ALS = advanced life support; BLS = basic life support; CPA = cardiopulmonary arrest; CPR = cardiopulmonary resuscitation; ECG = electrocardiography; EGDT = early goal-directed therapy; EtCO2 = end-tidal carbon dioxide; ILCOR = International Liaison Committee on Resuscitation; PCA = post cardiac arrest; RECOVER = Reassessment Campaign on Veterinary Resuscitation; ROSC = return of spontaneous circulation; VF = ventricular fibrillation; VT = ventricular tachycardia<\/span><\/p>\n","protected":false},"excerpt":{"rendered":"<p>The RECOVER initiative created the first consensus guidelines on veterinary resuscitation, and discusses the 5 domains of CPR for dogs and cats.<\/p>\n","protected":false},"author":1,"featured_media":12963,"comment_status":"open","ping_status":"open","sticky":false,"template":"","format":"standard","meta":{"_acf_changed":false,"iawp_total_views":32954,"footnotes":""},"categories":[364],"tags":[13],"class_list":["post-1135","post","type-post","status-publish","format-standard","has-post-thumbnail","hentry","category-january-february-2014","tag-peer-reviewed","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 v27.3) - https:\/\/yoast.com\/product\/yoast-seo-premium-wordpress\/ -->\n<title>CPR for Dogs and Cats: The RECOVER Guidelines<\/title>\n<meta name=\"description\" content=\"The RECOVER initiative created the first 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