Daniel J. Fletcher

RECOVER evidence and knowledge gap analysis on veterinary CPR. Part 7: Clinical guidelines.

OBJECTIVE To present a series of evidence-based, consensus guidelines for veterinary CPR in dogs and cats. DESIGN Standardized, systematic evaluation of the literature, categorization of relevant articles according to level of evidence and quality, and development of consensus on conclusions for application of the concepts to clinical practice. Questions in five domains were examined: Preparedness and Prevention, Basic Life Support, Advanced Life Support, Monitoring, and Post-Cardiac Arrest Care. Standardized worksheet templates were used for each question, and the results reviewed by the domain members, by the RECOVER committee, and opened for comments by veterinary professionals for 4 weeks. Clinical guidelines were devised from these findings and again reviewed and commented on by the different entities within RECOVER as well as by veterinary professionals. SETTING Academia, referral practice and general practice. RESULTS A total of 74 worksheets were prepared to evaluate questions across the five domains. A series of 101 individual clinical guidelines were generated. In addition, a CPR algorithm, resuscitation drug-dosing scheme, and postcardiac arrest care algorithm were developed. CONCLUSIONS Although many knowledge gaps were identified, specific clinical guidelines for small animal veterinary CPR were generated from this evidence-based process. Future work is needed to objectively evaluate the effects of these new clinical guidelines on CPR outcome, and to address the knowledge gaps identified through this process.

Evaluation of L-lactate and cardiac troponin I in horses undergoing emergency abdominal surgery.

OBJECTIVE To evaluate changes in plasma cardiac troponin I (cTnI) and L-lactate (LLt) as prognostic indicators in horses undergoing emergency abdominal surgery. DESIGN Prospective observational study. SETTING Veterinary teaching hospital. ANIMALS Thirty-four horses undergoing emergency abdominal surgery. INTERVENTIONS Serial blood sampling during various times during hospitalization (hospital admission, and 12, 24, 48, and 72 h postoperatively) evaluating cTnI and LLt concentrations. MEASUREMENTS AND MAIN RESULTS All horses required surgery for correction of a strangulating (n = 29) or nonstrangulating obstruction (n = 5) of the small or large intestine. Twenty-seven horses survived to discharge; 7 were euthanized either during (n = 1) or after (n = 6) surgery due to disease severity or systemic complications associated with the primary gastrointestinal lesion. Preoperative cTnI concentrations were increased above the normal reference interval in 24% of horses (8/34, median = 0.01 ng/mL, range = 0-12.23 ng/mL), whereas LLt concentrations were increased above the normal reference interval in 88% of horses (30/34, median = 3.37 mmol/L, range = 0.77-13.26 mmol/L). The LLt concentration was significantly higher (P < 0.05) in nonsurviving compared with surviving horses at admission, and at 24 and 72 hours postoperatively. No significant difference in the cTnI concentration was detected between groups at admission. However, the cTnI concentration was significantly higher (P<0.05) in nonsurviving compared with surviving horses at all time points postoperatively. CONCLUSIONS Measurement of both LLt and cTnI concentrations may provide information for prognostication in surgical colic horses. Marked increases in admission concentrations of LLt (median 7.56 mmol/L) and even moderate postoperative increases in cTnI concentration (median 0.97 ng/mL) may both indicate a poor prognosis in critically ill horses following abdominal surgery.Objective To evaluate changes in plasma cardiac troponin I (cTnI) and L-lactate (LLt) as prognostic indicators in horses undergoing emergency abdominal surgery. Design Prospective observational study. Setting Veterinary teaching hospital. Animals Thirty-four horses undergoing emergency abdominal surgery. Interventions Serial blood sampling during various times during hospitalization (hospital admission, and 12, 24, 48, and 72 h postoperatively) evaluating cTnI and LLt concentrations. Measurements and Main Results All horses required surgery for correction of a strangulating (n = 29) or nonstrangulating obstruction (n = 5) of the small or large intestine. Twenty-seven horses survived to discharge; 7 were euthanized either during (n = 1) or after (n = 6) surgery due to disease severity or systemic complications associated with the primary gastrointestinal lesion. Preoperative cTnI concentrations were increased above the normal reference interval in 24% of horses (8/34, median = 0.01 ng/mL, range = 0–12.23 ng/mL), whereas LLt concentrations were increased above the normal reference interval in 88% of horses (30/34, median = 3.37 mmol/L, range = 0.77–13.26 mmol/L). The LLt concentration was significantly higher (P < 0.05) in nonsurviving compared with surviving horses at admission, and at 24 and 72 hours postoperatively. No significant difference in the cTnI concentration was detected between groups at admission. However, the cTnI concentration was significantly higher (P<0.05) in nonsurviving compared with surviving horses at all time points postoperatively. Conclusions Measurement of both LLt and cTnI concentrations may provide information for prognostication in surgical colic horses. Marked increases in admission concentrations of LLt (median 7.56 mmol/L) and even moderate postoperative increases in cTnI concentration (median 0.97 ng/mL) may both indicate a poor prognosis in critically ill horses following abdominal surgery.

Pituitary-adrenal function in dogs with acute critical illness

OBJECTIVE To evaluate pituitary-adrenal function in critically ill dogs with sepsis, severe trauma, and gastric dilatation-volvulus (GDV). DESIGN Cohort study. ANIMALS 31 ill dogs admitted to an intensive care unit (ICU) at Washington State University or the University of Pennsylvania; all dogs had acute critical illness for < 48 hours prior to admission. PROCEDURES Baseline and ACTH-stimulated serum cortisol concentrations and baseline plasma ACTH concentrations were assayed for each dog within 24 hours after admission to the ICU. The change in cortisol concentrations (Delta-cortisol) was calculated for each dog. Morbidity and mortality data were recorded for each patient. RESULTS Overall, 17 of 31 (55%) acutely critically ill dogs had at least 1 biochemical abnormality suggestive of adrenal gland or pituitary gland insufficiency. Only 1 (3%) dog had an exaggerated response to ACTH stimulation. Dogs with Delta-cortisol < or = 83 nmol/L were 5.7 times as likely to be receiving vasopressors as were dogs with Delta-cortisol > 83 nmol/L. No differences were detected among dogs with sepsis, severe trauma, or GDV with respect to mean baseline and ACTH-stimulated serum cortisol concentrations, Delta-cortisol, and baseline plasma ACTH concentrations. CONCLUSIONS AND CLINICAL RELEVANCE Biochemical abnormalities of the hypothalamic-pituitary-adrenal axis indicative of adrenal gland or pituitary gland insufficiency were common in critically ill dogs, whereas exaggerated responses to ACTH administration were uncommon. Acutely ill dogs with Delta-cortisol < or = 83 nmol/L may be more likely to require vasopressors as part of the treatment plan.

Mycophenolate mofetil treatment in dogs with serologically diagnosed acquired myasthenia gravis: 27 cases (1999-2008).

OBJECTIVE-To compare clinical outcome in dogs with serologically diagnosed acquired myasthenia gravis (MG) treated with pyridostigmine bromide (PYR) with that of dogs treated with mycophenolate mofetil (MMF) and PYR (MMF + PYR). DESIGN-Retrospective case series. ANIMALS-27 dogs. PROCEDURES-Medical records from August 1999 through February 2008 were reviewed to identify dogs with serologically diagnosed acquired MG treated with PYR or MMF + PYR. Data collected for each dog included signalment, whether the dog had megaesophagus or pneumonia (or both), thyroid hormone concentration, remission, time to remission, and survival time. Rates for detection of clinical signs and survival time were compared. Survival time was estimated via the Kaplan-Meier method. Influence of drug treatment protocol on likelihood of remission, time to remission, and survival time was examined. Effects of MMF treatment, megaesophagus, pneumonia, and low serum thyroid hormone concentration on time to remission and survival time were also analyzed. RESULTS-12 dogs were treated with PYR, and 15 were treated with MMF + PYR. Mortality rates were 33% (PYR) and 40% (MMF + PYR). There was pharmacological remission in 5 and 6 dogs in the PYR and MMF + PYR groups, respectively. No significant differences were detected between treatment groups for remission rate, time to remission, or survival time. Megaesophagus, pneumonia, and low serum thyroid hormone concentration had no significant effect on time to remission or survival time for either treatment group. CONCLUSIONS AND CLINICAL RELEVANCE-The results did not support routine use of MMF for the treatment of dogs with acquired MG.

Accuracy of a continuous glucose monitoring system in dogs and cats with diabetic ketoacidosis.

OBJECTIVE (1) To determine the ability of a continuous interstitial glucose monitoring system (CGMS) to accurately estimate blood glucose (BG) in dogs and cats with diabetic ketoacidosis. (2) To determine the effect of perfusion, hydration, body condition score, severity of ketosis, and frequency of calibration on the accuracy of the CGMS. DESIGN Prospective study. SETTING University Teaching Hospital. ANIMALS Thirteen dogs and 11 cats diagnosed with diabetic ketoacidosis were enrolled in the study within 24 hours of presentation. INTERVENTIONS Once BG dropped below 22.2 mmol/L (400 mg/dL), a sterile flexible glucose sensor was placed aseptically in the interstitial space and attached to the continuous glucose monitoring device for estimation of the interstitial glucose every 5 minutes. MEASUREMENTS AND MAIN RESULTS BG measurements were taken with a portable BG meter every 2-4 hours at the discretion of the primary clinician and compared with CGMS glucose measurements. The CGMS estimates of BG and BG measured on the glucometer were strongly associated regardless of calibration frequency (calibration every 8 h: r=0.86, P<0.001; calibration every 12 h: r=0.85, P<0.001). Evaluation of this data using both the Clarke and Consensus error grids showed that 96.7% and 99% of the CGMS readings, respectively, were deemed clinically acceptable (Zones A and B errors). Interpatient variability in the accuracy of the CGMS glucose measurements was found but was not associated with body condition, perfusion, or degree of ketosis. A weak association between hydration status of the patient as assessed with the visual analog scale and absolute percent error (Spearmans rank correlation, rho=-0.079, 95% CI=-0.15 to -0.01, P=0.03) was found, with the device being more accurate in the more hydrated patients. CONCLUSIONS The CGMS provides clinically accurate estimates of BG in patients with diabetic ketoacidosis.

Development and Evaluation of a High-Fidelity Canine Patient Simulator for Veterinary Clinical Training

High-fidelity human patient simulators have been used for decades in medical education to provide opportunities for students to practice technical skills, diagnostic and therapeutic planning, and communication skills in a safe environment. A high-fidelity canine patient simulator (CPS) was developed using components from a human patient simulator and a low-fidelity foam core canine mannequin. Ninety-six veterinary students participated in cardiopulmonary arrest scenarios in groups of three to five students. Afterwards, participants were asked to complete an anonymous online survey describing their experiences. A total of 70 students (73%) completed the survey. All of the students (100%) felt that the simulator session expanded their cardiopulmonary resuscitation (CPR) knowledge base, and 97% responded that their skills and abilities had improved. Students also expressed positive opinions about the CPS, with 89% agreeing or strongly agreeing that the CPS was realistic and 73% agreeing or strongly agreeing that the scenarios generated emotions similar to real clinical situations. Most participants (98.5%) agreed or strongly agreed that the simulator was an engaging learning experience. Students commonly commented that the simulations allowed them to practice communication and teamwork skills and were more effective than paper-based, problem-oriented learning opportunities and lecture. Students also commented that they wanted more opportunities to participate in simulation exercises. These results suggest that high-fidelity veterinary simulation is an engaging educational methodology that addresses some limitations of other forms of problem-based learning. More studies are needed to quantitatively determine the effectiveness of this novel veterinary educational technology in comparison with more traditional approaches.

RECOVER evidence and knowledge gap analysis on veterinary CPR. Part 3: Basic life support.

OBJECTIVE To systematically examine the evidence on basic life support (BLS) in veterinary CPR and to determine knowledge gaps. DESIGN Standardized, systematic evaluation of the literature, categorization of relevant articles according to level of evidence and quality, and development of consensus on conclusions for application of the concepts to clinical practice. Relevant questions were answered on a worksheet template and reviewed by the Reassessment Campaign on Veterinary Resuscitation (RECOVER) BLS domain members, by the RECOVER committee and opened for comments by veterinary professionals for 30 days. SETTING Academia, referral practice, and general practice. RESULTS Sixteen worksheets were prepared to evaluate techniques for chest compression and ventilation strategies as well as identification of cardiopulmonary arrest (CPA). Major recommendations arising from this evidence review include performing chest compressions at a rate of at least 100/min at a compression depth of one-third to half the width of the chest with minimal pauses, and early instigation of ventilation at a rate of 8-10 breaths/min in intubated patients, or using a 30:2 compression/ventilation ratio in nonintubated patients. CONCLUSIONS Although veterinary clinical trials are lacking, much of the experimental literature on BLS utilized canine models. The major conclusions from this analysis of the literature are the importance of early identification of CPA, and immediate initiation of BLS in these patients. Many knowledge gaps exist, most importantly in our understanding of the optimal hand placement and technique for chest compressions, warranting coordinated future studies targeted at questions of relevance to differences between veterinary species and humans.

Admission base excess as a predictor of transfusion requirement and mortality in dogs with blunt trauma: 52 cases (2007–2009)

OBJECTIVE To evaluate the ability of admission base excess (ABE) to predict blood transfusion requirement and mortality in dogs following blunt trauma. DESIGN Retrospective study 2007-2009. SETTING University Veterinary Teaching Hospital. ANIMALS Fifty-two dogs admitted to the intensive care unit for treatment following blunt trauma. MEASUREMENTS AND MAIN RESULTS Animals requiring red blood cell transfusion (N = 8) had significantly lower ABE than those not requiring transfusion (N = 44; median base excess [BE] = -8.4 versus -4.7, P = .0034), while there was no difference in admission packed cell volume (PCV) or age. Animals that died or were euthanized due to progression of signs (N = 5) had lower median ABE than those that survived (N = 47; median BE = -7.3 versus -4.9, P = 0.018). Admission PCV and age were not significantly different between survivors and nonsurvivors. Receiver operator characteristic curve analysis showed an ABE cutoff of -6.6 was 88% sensitive and 73% specific for transfusion requirement (P < 0.001), and a cutoff of -7.3 was 81% sensitive and 80% specific for survival (P < 0.001). Multivariate logistic regression analysis demonstrated that ABE was a predictor of transfusion requirement that was independent of overall severity of injury as measured by the Animal Triage Trauma (ATT) score, but a similar analysis showed that only ATT was an independent predictor of survival. CONCLUSIONS The ABE in dogs with blunt trauma was a predictor of mortality and blood transfusion requirement within 24 hours.

Evaluation of tranexamic acid and ϵ-aminocaproic acid concentrations required to inhibit fibrinolysis in plasma of dogs and humans

OBJECTIVE To determine minimum plasma concentrations of the antifibrinolytic agents tranexamic acid (TEA) and ε-aminocaproic acid (EACA) needed to completely inhibit fibrinolysis in canine and human plasma after induction of hyperfibrinolysis. SAMPLES Pooled citrated plasma from 7 dogs and commercial pooled citrated human plasma. PROCEDURES Concentrations of EACA from 0 μg/mL to 500 μg/mL and of TEA from 0 μg/mL to 160 μg/mL were added to pooled citrated canine and human plasma. Hyperfibrinolysis was induced with 1,000 units of tissue plasminogen activator/mL, and kaolin-activated thromboelastography was performed in duplicate. The minimum concentrations required to completely inhibit fibrinolysis 30 minutes after maximum amplitude of the thromboelastography tracing occurred were determined. RESULTS Minimum plasma concentrations necessary for complete inhibition of fibrinolysis by EACA and TEA in pooled canine plasma were estimated as 511.7 μg/mL (95% confidence interval [CI], 433.2 to 590.3 μg/mL) and 144.7 μg/mL (95% CI, 125.2 to 164.2 μg/mL), respectively. Concentrations of EACA and TEA necessary for complete inhibition of fibrinolysis in pooled human plasma were estimated as 122.0 μg/mL (95% CI, 106.2 to 137.8 μg/mL) and 14.7 μg/mL (95% CI, 13.7 to 15.6 μg/mL), respectively. CONCLUSIONS AND CLINICAL RELEVANCE Results supported the concept that dogs are hyperfibrinolytic, compared with humans. Higher doses of EACA and TEA may be required to fully inhibit fibrinolysis in dogs.

RECOVER evidence and knowledge gap analysis on veterinary CPR. Part 1: Evidence analysis and consensus process: collaborative path toward small animal CPR guidelines.

Objective To describe the methodology used by the Reassessment Campaign on Veterinary Resuscitation (RECOVER) to evaluate the scientific evidence relevant to small animal CPR and to compose consensus-based clinical CPR guidelines for dogs and cats. Design This report is part of a series of 7 articles on the RECOVER evidence and knowledge gap analysis and consensus-based small animal CPR guidelines. It describes the organizational structure of RECOVER, the evaluation process employed, consisting of standardized literature searches, the analysis of relevant articles according to study design, species and predefined quality markers, and the drafting of clinical CPR guidelines based on these data. Therefore, this article serves as the methodology section for the subsequent 6 RECOVER articles. Setting Academia, referral practice. Results RECOVER is a collaborative initiative that systematically evaluated the evidence on 74 topics relevant to small animal CPR and generated 101 clinical CPR guidelines from this analysis. All primary contributors were veterinary specialists, approximately evenly split between academic institutions and private referral practices. The evidence evaluation and guideline drafting processes were conducted according to a predefined sequence of steps designed to reduce bias and increase the repeatability of the findings, including multiple levels of review, culminating in a consensus process. Many knowledge gaps were identified that will allow prioritization of research efforts in veterinary CPR. Conclusions Collaborative systematic evidence review is organizationally challenging but feasible and effective in veterinary medicine. More experience is needed to refine the process.OBJECTIVE To describe the methodology used by the Reassessment Campaign on Veterinary Resuscitation (RECOVER) to evaluate the scientific evidence relevant to small animal CPR and to compose consensus-based clinical CPR guidelines for dogs and cats. DESIGN This report is part of a series of 7 articles on the RECOVER evidence and knowledge gap analysis and consensus-based small animal CPR guidelines. It describes the organizational structure of RECOVER, the evaluation process employed, consisting of standardized literature searches, the analysis of relevant articles according to study design, species and predefined quality markers, and the drafting of clinical CPR guidelines based on these data. Therefore, this article serves as the methodology section for the subsequent 6 RECOVER articles. SETTING Academia, referral practice. RESULTS RECOVER is a collaborative initiative that systematically evaluated the evidence on 74 topics relevant to small animal CPR and generated 101 clinical CPR guidelines from this analysis. All primary contributors were veterinary specialists, approximately evenly split between academic institutions and private referral practices. The evidence evaluation and guideline drafting processes were conducted according to a predefined sequence of steps designed to reduce bias and increase the repeatability of the findings, including multiple levels of review, culminating in a consensus process. Many knowledge gaps were identified that will allow prioritization of research efforts in veterinary CPR. CONCLUSIONS Collaborative systematic evidence review is organizationally challenging but feasible and effective in veterinary medicine. More experience is needed to refine the process.