RECOVER evidence and knowledge gap analysis on veterinary CPR. Part 6: Post‐cardiac arrest care

Abstract

Objective -To systematically examine the evidence for interventions after the return of spontaneous circulation (ROSC) on outcomes from veterinary cardiopulmonary resuscitation and to determine important 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 post-cardiac arrest care. Setting -Academia, referral practice, and general practice. Results -Fifteen standardized clinical questions important for post-cardiac arrest care were asked and research articles relevant to answering these questions were identified through structured, explicit literature database searches. The majority of these articles report research in species other than dogs or cats or consisted of experimental work in canine cardiac arrest models. Outcome metrics reported in these studies widely varied and ranged from quantification of mechanistic endpoints, such as elaboration of reactive oxygen species, to survival, and functional neurologic outcome. Conclusions -Despite the near complete absence of clinical veterinary studies, the process allowed the formulation of statements for several postcardiac arrest treatments that were either supportive, such as mild therapeutic hypothermia or controlled reoxygenation, or neutral, such as for mannitol administration or seizure prophylaxis. Evidence grading allowed transparency in regards to the strength of these recommendations. Moreover, numerous knowledge gaps emerged that will allow generation of a road map for progress in veterinary post-cardiac arrest care.

Utstein‐style guidelines on uniform reporting of in‐hospital cardiopulmonary resuscitation in dogs and cats. A RECOVER statement

“…Foremost, a large proportion of patients that initially survived the CPA event will continue to die during the PCA phase . PCA care guidelines have been developed for human and veterinary medicine and PCA care was demonstrated to improve survival in people with OHCA and IHCA . PCA care elements are only indirectly included in these recommendations as the hospital characterization describes the presence of an intensive care unit and specialists.…”

Post–Cardiac Arrest Care

“…Thus patients should be monitored for seizures and treated accordingly if they occur (see Chapter 82). 5 Thus the use of mannitol or hypertonic saline can be considered if the presence of cerebral edema is suggested by clinical signs, such as coma, stupor, or decerebrate posture. 33 This may be particularly relevant in animals that remain comatose or are sedated, because nonconvulsive seizure activity may be present and difficult to diagnose.…”

RECOVERevidence and knowledge gap analysis on veterinaryCPR. Part 1: Evidence analysis and consensus process: collaborative path toward small animalCPRguidelines

“…An example for a Class IIa recommendation is that the use of atropine is reasonable in dogs and cats with asystole or PEA potentially associated with increased vagal tone (IIa‐B) . A Class IIb recommendation is that seizure prophylaxis with barbiturates in dogs and cats post‐cardiac arrest may be considered (IIb‐B) . If at any level of evidence an intervention was considered to be more harmful than beneficial, it was assigned a Class III recommendation.…”

“…If at any level of evidence an intervention was considered to be more harmful than beneficial, it was assigned a Class III recommendation. An example is that fast rewarming at a rate > 1°C/h is not recommended in hypothermic dogs and cats post‐cardiac arrest (III‐A) …”

“…The objective of each domain manuscript was to provide the reader with a succinct but comprehensive overview of all evidence evaluated, and thus was composed as a synopsis of the science evaluated during the RECOVER worksheet process. Accordingly, the knowledge gaps were also included in these 5 articles . The WS authors were asked to critically review the drafted manuscript sections that related to their topic prior to finalizing the articles.…”