Manuel Boller

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.

A rodent model of emergency cardiopulmonary bypass resuscitation with different temperatures after asphyxial cardiac arrest

BACKGROUND The use of emergency cardiopulmonary bypass (ECPB) resuscitation after cardiac arrest may offer hope for survival when standard ACLS therapies fail. However, whether cooling adds benefit to ECPB is unknown and we lack an ECPB rodent model for experimental studies. We sought to (a) develop a 72 h survival rodent model using ECPB to treat asphyxial cardiac arrest and (b) use this new model to evaluate early mild and moderate hypothermia versus normothermia during ECPB resuscitation. METHODS After 8 min of normothermic asphyxia, three groups of rats were resuscitated with ECPB at 37 degrees C (NORM), 34 degrees C (MILD) and 30 degrees C (MOD) for 1h (n=10 each). During the second resuscitation hour, ECPB was discontinued, ventilatory support was provided and body temperatures were maintained at 37 degrees C for NORM, 34 degrees C for MILD, and from 30 degrees C gradually up to 34 degrees C in 1h for MOD animals. From hours 3 to 8, body temperature was maintained at 37 degrees C for NORM and 34 degrees C for MILD and MOD animals. RESULTS All rats were initially resuscitated by ECPB. After 72 h, neurological outcome and survival in the MILD (60% survival) and MOD (80%) groups were significantly better than in the NORM (0%) group (p<0.05). Overall performance recovery in the MOD group was best (vs. the NORM group), while the MILD group had an intermediate outcome. CONCLUSIONS A rodent model of ECPB is feasible and useful for resuscitation studies. The addition of early mild and moderate hypothermia to ECPB resuscitation significantly improves survival compared with normothermic ECPB in rats.

The clinical practice of CPCR in small animals: an internet-based survey.

OBJECTIVE To characterize the provision of CPCR by small animal veterinarians in clinical practice and to assess how this practice varies among different levels of expertise. DESIGN Internet-based survey. SETTING Academia, referral practice, and general practice. SUBJECTS Six hundred and two small animal veterinarians in clinical practice. Respondents were grouped a priori according to level of expertise: board-certified (ACVECC, ACVA, ECVAA) specialists; general practitioners in emergency clinics; general practitioners in general practice (GPG). INTERVENTIONS Email invitations to the online questionnaire were disseminated via a veterinary internet platform and mailing list server discussion groups. Questions explored respondent characteristics, CPCR preparedness, infrastructural and personnel resources, and techniques of basic and advanced life support. MAIN RESULTS In this group of practitioners, the majority (65%) were in general practice. GPG were more likely to perform CPCR <5 times per year and to have 3 or fewer members on their resuscitation team. Most practitioners have a crash cart and drug-dosing chart available. GPG were less likely to obtain resuscitation codes on their patients, and less likely to use end-tidal carbon dioxide monitoring or defibrillation. Intubation, oxygen supplementation, vascular access, and external thoracic compressions were widely used, however, GPG were more likely to use lower chest compression rates. Drugs used for CPCR differed among the groups with GPG more likely to use doxapram and glucocorticoids. CONCLUSIONS CPCR is heterogeneously performed in small animal veterinary medicine; differences exist, both among and within different types of veterinarians with varying levels of expertise, in respect to available infrastructure, personnel and CPCR techniques used.

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.

Small animal cardiopulmonary resuscitation requires a continuum of care: proposal for a chain of survival for veterinary patients

JAVMA, Vol 240, No. 5, March 1, 2012 C efforts have been made to advance methods of CPR since its introduction 50 years ago. As the understanding of CPR has evolved, so has the definition of its major components that contribute to survival. Twenty years ago, the AHA introduced the so-called chain of survival, which serves as a metaphor for the importance of approaching CPA in a timely, sequential, and comprehensive manner. As originally described, the components, or links, in this chain of survival included early access to help, early initiation of CPR, early defibrillation, and early advanced cardiac life support. A number of recent developments in CPR research have encouraged the focused optimization of individual links in the chain of survival, with the goal of optimizing the overall CPR process. The AHA published new guidelines for CPR in humans in October 2010. These guidelines, which are revised every 5 years, are based on an evidence evaluation process that serves as the foundation for consensus treatment recommendations. In essence, the AHA aims to identify elements that could further optimize each link of the chain of survival. The first major opportunity for improvement lies in the fact that laypersons and health professionals often do not perform CPR according to published guidelines and that this noncompliance is associated with reduced survival. Focused efforts are being made to allocate resources that will improve compliance with these guidelines through novel educational and technical tools, and the AHA 2010 CPR guidelines include a new section dedicated to education and implementation.Additionally, recent studies have found clear evidence of the neuroprotective effects of mild therapeutic hypothermia for human patients after CPA, even if administered hours after ROSC. This and the fact that 60% to 70% of humans that have CPA and achieve ROSC subsequently die of post–cardiac arrest syndrome led to the inclusion of a dedicated section on post–cardiac arrest care in the newest AHA CPR Small animal cardiopulmonary resuscitation requires a continuum of care: proposal for a chain of survival for veterinary patients

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.

Feasibility of intra-arrest hypothermia induction: A novel nasopharyngeal approach achieves preferential brain cooling.

AIM In patients with cardiopulmonary arrest, brain cooling may improve neurological outcome, especially if applied prior to or during early reperfusion. Thus it is important to develop feasible cooling methods for pre-hospital use. This study examines cerebral and compartmental thermokinetic properties of nasopharyngeal cooling during various blood flow states. METHODS Ten swine (40+/-4kg) were anesthetized, intubated and monitored. Temperature was determined in the frontal lobe of the brain, in the aorta, and in the rectum. After the preparatory phase the cooling device (RhinoChill system), which produces evaporative cooling in the nasopharyngeal area, was activated for 60min. The thermokinetic response was evaluated during stable anaesthesia (NF, n=3); during untreated cardiopulmonary arrest (ZF, n=3); during CPR (LF, n=4). RESULTS Effective brain cooling was achieved in all groups with a median cerebral temperature decrease of -4.7 degrees C for NF, -4.3 degrees C for ZF and -3.4 degrees C for LF after 60min. The initial brain cooling rate however was fastest in NF, followed by LF, and was slowest in ZF; the median brain temperature decrease from baseline after 15min of cooling was -2.48 degrees C for NF, -0.12 degrees C for ZF, and -0.93 degrees C for LF, respectively. A median aortic temperature change of -2.76 degrees C for NF, -0.97 for LF and +1.1 degrees C for ZF after 60min indicated preferential brain cooling in all groups. CONCLUSION While nasopharyngeal cooling in swine is effective at producing preferential cerebral hypothermia in various blood flow states, initial brain cooling is most efficient with normal circulation.

Emergency Cardiopulmonary Bypass: A Promising Rescue Strategy for Refractory Cardiac Arrest

SUMMARY ECPB is a relatively new, advanced resuscitation method that is growing in technicalsophistication, shows promising experimental data, and is expanding in clinicalpractice. Experimental data and clinical studies suggest its ability to be highlyeffective at producing ROSC for refractory cardiac arrest. Currently however, themajority of patients who achieve ROSC with ECPB do not survive long-term with goodneurologic function. Despite this limitation, survival rates may be far better thanstandard ALS care. ConventionalCPRExtracorporeal CPRwith cardiopulmonary bypass plus intra-aortic balloon pumpingPost-ROSC cooling; extracorporeal cooling methodsInductionER arrival°C36353433InductionCoronaryreperfusiontherapyusing PCICooling for 3 daysIntra-arrest cooling; cold fluid and extracorporeal cooling methodsCooling for 3 daysRewarming for 3 daysRewarming for 3 daysCore temperature Fig. 3. Protocol of ECPR for induction of hypothermia with percutaneous coronary intervention(PCI). After arrival at the emergency room, ECPR using emergency cardiopulmonary bypass plusintra-aortic balloon pumping was immediately performed. Subsequently, emergency coronaryangiography with PCI was performed in cases of suspected acute coronary syndrome. The goalwastoreachatargettemperatureof34°Cwithin6hoursinthepost-ROSCcoolinggroup(

RECOVER evidence and knowledge gap analysis on veterinary CPR. Part 4: Advanced life support

Objective To systematically evaluate the evidence of the effect of advanced life support techniques on outcome in veterinary cardiopulmonary resuscitation (CPR) and to outline 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. Setting Academia, referral practice, and general practice Results Sixteen population, intervention, control group, outcome questions were evaluated to determine if recommendations could be made concerning drug therapy, including vasopressors, vagolytics, corticosteroids, reversal agents, buffer therapy, and correction of electrolyte disturbances. Electrical defibrillation strategies as well as other advanced interventions such as open-chest CPR, impedance threshold devices, and special considerations regarding anesthesia-related cardiopulmonary arrest (CPA) were also investigated. Conclusions There is strong evidence supporting the use of standard-dose (0.01 mg/kg) epinephrine in CPR, as well as early electrical defibrillation for animals experiencing CPA due to ventricular fibrillation or pulseless ventricular tachycardia, preferentially using a biphasic defibrillator. For CPA due to certain causes and with the availability of advanced postcardiac arrest support, open chest CPR is preferred. Many knowledge gaps regarding other pharmacologic and advanced therapies were identified, and further studies are recommended to better systematically address these questions.OBJECTIVE To systematically evaluate the evidence of the effect of advanced life support techniques on outcome in veterinary cardiopulmonary resuscitation (CPR) and to outline 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. SETTING Academia, referral practice, and general practice RESULTS Sixteen population, intervention, control group, outcome questions were evaluated to determine if recommendations could be made concerning drug therapy, including vasopressors, vagolytics, corticosteroids, reversal agents, buffer therapy, and correction of electrolyte disturbances. Electrical defibrillation strategies as well as other advanced interventions such as open-chest CPR, impedance threshold devices, and special considerations regarding anesthesia-related cardiopulmonary arrest (CPA) were also investigated. CONCLUSIONS There is strong evidence supporting the use of standard-dose (0.01 mg/kg) epinephrine in CPR, as well as early electrical defibrillation for animals experiencing CPA due to ventricular fibrillation or pulseless ventricular tachycardia, preferentially using a biphasic defibrillator. For CPA due to certain causes and with the availability of advanced postcardiac arrest support, open chest CPR is preferred. Many knowledge gaps regarding other pharmacologic and advanced therapies were identified, and further studies are recommended to better systematically address these questions.

Presumed secondary immune‐mediated haemolytic anaemia following elapid snake envenomation and its treatment in four dogs

CASE SERIES This case series describes secondary immune-mediated haemolytic anaemia (IMHA) in four dogs following elapid snake envenomation and its treatment. All the dogs initially presented with clinical signs commensurate with mainland tiger snake (Notechis scutatus) envenomation. None of the dogs was anaemic at the time of presentation. IMHA was diagnosed 3-9 days following snake envenomation. The trigger for IMHA was unclear in each case and may have been a component of the snake venom, antivenom, fresh frozen plasma, concurrent morbidity, administered drugs or a combination thereof. Three of the four dogs received immunosuppressive therapy comprising corticosteroids with or without azathioprine. Resolution of the IMHA was documented 6 weeks after diagnosis for one dog and 9 months after diagnosis for two dogs, with one dog lost to follow-up. CONCLUSION IMHA is a potential complicating factor of elapid snake envenomation and its treatment in dogs, and should be considered as a differential diagnosis for a persistent or worsening anaemia. Both the incidence and aetiopathogenesis of IMHA in the context of elapid snake envenomation and its treatment in dogs are unknown and require further examination.