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BLS-01-v1
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RECOVER 2.0 Worksheet
QUESTION ID: BLS-01
PICO Question:
In cats and dogs in CPA (P), does incomplete chest wall recoil (I) compared to allowing complete chest wall recoil (via 50:50 duty cycle, decreasing fatigue and leaning) (C), improve ... (O)?
Outcomes:
Favorable neurologic outcome, Surrogate marker(s) of perfusion, Survival to discharge, ROSC
Prioritized Outcomes (1= most critical; final number = least important):
- Favorable neurologic outcome
- Survival to discharge
- ROSC
- Surrogate markers of perfusion
Domain chairs: Steve Epstein, Kate Hopper; final edits by Jamie Burkitt
Evidence evaluators: Jennifer Hess, Claire Sharp
Conflicts of interest: none
Search strategy: See attached document
Evidence Review:
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Study Design |
Reduced Quality Factors
0 = no serious, - = serious,
- - = very serious |
Positive Quality Factors
0 = none, + = one, ++ = multiple |
Dichotomous Outcome Summary |
Non-Dichotomous Outcome Summary
Brief description |
Overall Quality
High, moderate, low, |
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No of studies |
Study Type |
RoB |
Indirectness |
Imprecision |
Inconsistency |
Large Effect |
Dose-Response |
Confounder |
# Intervention with Outcome |
# Control with Outcome |
RR (95% CI) |
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Outcome: Surrogate markers of perfusion |
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4 |
EXP |
0 |
- -
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0 |
0 |
0 |
+ |
0 |
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Various surrogate markers of perfusion are improved when shorter duty cycles and less fraction of time spent “leaning” on the chest occur.
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Moderate |
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PICO Question Summary
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Introduction |
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Incomplete chest wall recoil during CPR may increase intrathoracic pressure between chest compressions and thereby decrease venous return. Leaning on the chest between compressions will impair chest wall recoil and has been found to occur commonly in human clinical studies. The current human and previous veterinary guidelines recommend allowing for complete chest wall recoil between compressions based primarily on experimental data. This question investigates whether impaired chest wall recoil affects outcome in dogs and cats undergoing CPR.
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Consensus on science |
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For the most critical outcomes of favorable neurologic outcome, survival to discharge and ROSC, we identified no studies that address the PICO question.
Outcome 4: Surrogate markers of perfusion:
Four experimental studies (moderate level of evidence, downgraded for serious indirectness) in a porcine ventricular fibrillation model of cardiopulmonary arrest were identified, 2 of which document that leaning decreases cardiac index and left ventricular myocardial index.1,2 Two studies evaluated different duty cycles and documented decreased duty cycle or maximizing the recoil phase increased cerebral or myocardial perfusion pressure; we considered adequate time in non-compression to be important for left ventricular filling during the recoil phase.3,4 Cerebral perfusion pressure and aortic pressure were optimized by a 50:50 duty cycle of compression : non-compression in 8-week-old piglets.4
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Treatment recommendations |
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We recommend allowing full chest wall recoil between chest compressions in dogs and cats undergoing CPR (strong recommendation, moderate quality of evidence).
We recommend targeting a duty cycle of 50:50 for compression : non-compression during CPR in dogs and cats (strong recommendation, moderate quality of evidence).
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Justification of treatment recommendation |
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All pertinent evidence to date shows improved surrogate markers of perfusion when there is adequate opportunity for full chest wall recoil.
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Knowledge gaps |
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Whether allowing full chest wall recoil during CPR in dogs and cats improves neurologic outcome, survival to discharge, or ROSC is unknown.
There is no supporting evidence to address the PICO question in human clinical trials, nor in dogs and cats in any setting.
Whether veterinary health care providers can maintain adequate chest compression technique without leaning between compressions for a full 2-minute BLS cycle during CPR in dogs and cats of variable size and conformations is unknown.
It is unclear whether health care providers are able to assess themselves and others for leaning during the recoil phase of CPR in dogs and cats.
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References
1. Yannopoulos D, McKnite S, Aufderheide TP, et al. Effects of incomplete chest wall decompression during cardiopulmonary resuscitation on coronary and cerebral perfusion pressures in a porcine model of cardiac arrest. Resuscitation. 2005;64(3):363-372.
2. Zuercher M, Hilwig RW, Ranger-Moore J, et al. Leaning during chest compressions impairs cardiac output and left ventricular myocardial blood flow in piglet cardiac arrest. Crit Care Med. 2010;38(4):1141-1146.
3. Dean JM, Koehler RC, Schleien CL, et al. Age-related effects of compression rate and duration in cardiopulmonary resuscitation. J Appl Physiol 1985. 1990;68(2):554-560.
4. Dean JM, Koehler RC, Schleien CL, et al. Improved blood flow during prolonged cardiopulmonary resuscitation with 30% duty cycle in infant pigs. Circulation. 1991;84(2):896-904.
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