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BLS-07-v1
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RECOVER 2.0 Worksheet
QUESTION ID: BLS-07
PICO Question:
In cats or dogs in CPA (P), does the use of any other specific rate for external chest compressions (I) compared to external chest compression rate of 100-120 / minute (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: Liron Oron, Jenefer Stillion
Conflicts of interest: None to declare
Search strategy: See attached document
Evidence Review:
|
Study Design |
Reduced Quality Factors
0 = not 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) |
|
|
|
Outcome: Favorable Neurologic Outcome |
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|
2 |
EXP |
- |
- |
- |
0 |
0 |
0 |
+ |
|
|
|
|
Very low |
|
3 |
OBS |
- -
|
- |
0
|
0
|
0
|
0 |
0 |
|
|
|
|
Very low
|
|
Outcome: Survival to discharge |
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|
4 |
OBS |
- - |
- - |
- |
0 |
0 |
0 |
0 |
|
|
|
|
Very low |
|
Outcome: ROSC |
|||||||||||||
|
3 |
EX |
- |
0 |
- |
0 |
0 |
0 |
0 |
|
|
|
|
Very Low |
|
5 |
OBS |
- - |
- |
- |
0 |
0 |
0 |
0 |
|
|
|
|
Very Low |
PICO Question Summary
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Introduction |
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The current human and previous veterinary guidelines recommend a chest compression rate of 100-120/minute based primarily on experimental and human data.1,2 This PICO question investigated whether other compression rates are superior to 100-120 in dogs and cats during CPR.
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Consensus on science |
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Outcome 1: Favorable neurologic outcome:
For the most critical outcome of favorable neurological outcome, we identified 2 experimental studies (very low quality of evidence, downgraded for risk of bias, indirectness, and imprecision, and upgraded for effect found despite confounding) and 3 observational studies (very low quality of evidence downgraded for very serious risk of bias and serious indirectness) that addressed the PICO question. 3–7 Two experimental animal studies, including 1 in dogs, found chest compression rates substantially lower than 100-120/min (60 and 80/min) were associated with poorer neurological outcome than a chest compression rate of 100.3,4 Two observational studies in adults supported a compression rate of 100-120/min.5,6 One pediatric study found that a compression rate of 80-99 had a more favorable neurological outcome in a very small number of children.7 Due to confounding factors in that study, its authors recommended against changing guidelines based on their findings.
Outcome 2: Survival to discharge:
For the next critical outcome of survival to discharge, we identified 4 observational studies in people (very low quality of evidence, downgraded for very serious risk of bias, very serious indirectness, and serious imprecision) that addressed the PICO question. 7–10 The same pediatric study cited above7 also documented that a CC rate of < 100/min in a very small portion of patients was associated with greater survival to discharge.7 Authors of that study recommended against changing compression recommendations from existing guidelines. Two studies (1 adult and 1 pediatric) found no difference between intervention and comparator group.8,9 One large scale adult human study showed that the non-target compression rate groups (<100 and >120/minute) were associated with worse survival to discharge rates.10
Outcome 3: ROSC:
For the critical outcome of ROSC, we identified 3 experimental studies (very low quality of evidence, downgraded for serious risk of bias and serious imprecision) and 5 observational studies (very low quality of evidence, downgraded for very serious risk of bias, serious indirectness, and serious imprecision).3,4,6–8,10–12
Of the 3 experimental studies, 1 canine3 and 1 swine study4 found lower ROSC rates with chest compression rates < 100/min, while 1 piglet study identified no difference between a compression rate of 90 and 120/minute.11 Of 5 observational studies, 2 studies in human pediatric patients found no difference in ROSC with chest compression rates outside the range of 100-120.7,8 One adult human study of IHCA found higher ROSC rates with chest compression rates of 121 to 140 compared to 100-120 or > 140/min.6 In a large OHCA adult human study there was no difference in ROSC with a chest compression rate of 80-99 or > 120 when compared to 100-119/min.10 In a prospective, observational veterinary study there was no difference in the median chest compression rate between patients with and without ROSC.12
Evidence was not summarized for Outcome 4: Surrogate markers of perfusion because of the evidence available for the more critical outcomes above. |
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Treatment recommendation |
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We recommend using a chest compression rate of 100-120 compressions per minute during CPR in dogs and cats. (strong recommendation, very low quality of evidence).
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Justification of treatment recommendation |
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The preponderance of evidence supports chest compression rates of 100-120 / minute to optimize the most critical outcomes of favorable neurological outcome and survival to discharge. Although some studies are neutral as to the impact on these outcomes, others show improvement in the less critical outcome of ROSC when chest compression rates outside this range are used. However, there is no evidence that a chest compression rate other than 100-120 / minute improves any critical outcome in dogs and cats.
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Knowledge gaps |
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There is no clinical evidence to support a specific chest compression rate in dogs or in cats.
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References
1. Panchal AR, Bartos JA, Cabañas JG, et al. Part 3: Adult Basic and Advanced Life Support: 2020 American Heart Association Guidelines for Cardiopulmonary Resuscitation and Emergency Cardiovascular Care. Circulation. 2020;142(16_suppl_2):S366-S468.
2. Fletcher DJ, Boller M, Brainard BM, et al. RECOVER evidence and knowledge gap analysis on veterinary CPR. Part 7: Clinical guidelines: RECOVER clinical guidelines. J Vet Emerg Crit Care. 2012;22(s1):S102-S131.
3. Feneley MP, Maier GW, Kern KB, et al. Influence of compression rate on initial success of resuscitation and 24 hour survival after prolonged manual cardiopulmonary resuscitation in dogs. Circulation. 1988;77(1):240-250.
4. Wu JY, Li CS, Liu ZX, Wu CJ, Zhang GC. A comparison of 2 types of chest compressions in a porcine model of cardiac arrest. Am J Emerg Med. 2009;27(7):823-829.
5. Duval S, Pepe PE, Aufderheide TP, et al. Optimal Combination of Compression Rate and Depth During Cardiopulmonary Resuscitation for Functionally Favorable Survival. JAMA Cardiol. Published online 2019.
6. Kilgannon JH, Kirchhoff M, Pierce L, et al. Association between chest compression rates and clinical outcomes following in-hospital cardiac arrest at an academic tertiary hospital. Resuscitation. 2017;110:154-161.
7. Sutton RM, Reeder RW, Landis W, et al. Chest compression rates and pediatric in-hospital cardiac arrest survival outcomes. Resuscitation. 2018;130:159-166.
8. Sutton RM, Case E, Brown SP, et al. A quantitative analysis of out-of-hospital pediatric and adolescent resuscitation quality – A report from the ROC epistry-cardiac arrest. Resuscitation. 2015;93:150-157.
9. Idris AH, Guffey D, Aufderheide TP, et al. Relationship between chest compression rates and outcomes from cardiac arrest. Circulation. 2012;125(24):3004-3012.
10. Idris AH, Guffey D, Pepe PE, et al. Chest Compression Rates and Survival Following Out-of-Hospital Cardiac Arrest. Crit Care Med. 2015;43(4):840-848.
11. Li ES, Cheung PY, Lee TF, et al. Return of spontaneous circulation is not affected by different chest compression rates superimposed with sustained inflations during cardiopulmonary resuscitation in newborn piglets. PLoS ONE. 2016;11(6).
12. McIntyre RL, Hopper K, Epstein SE. Assessment of cardiopulmonary resuscitation in 121 dogs and 30 cats at a university teaching hospital (2009-2012). J Vet Emerg Crit Care San Antonio. 2014;24(6):693-704.
Supporting information:
Favorable neurologic outcome:
Experimental: One swine model showed CC rate of 80 had worse outcome than CC rate of 100.
Dogs with CC rate of 120 had more favorable neurological outcome at 24 hrs when compared to dogs with CC rate of 60.
Observational: One study showed a CC rate of 107 and depth of 4.7 cm was most associated with positive outcome. One study showed <100 or > 120 not different than 100-120, 1 pediatric study: 80-99 associated with favorable outcome
Survival to discharge:
Observational: In pediatric patients with OHCA, there was no difference in survival to discharge between patients receiving CC rate 100-120 cpm versus those that did not. Large adult human study found CC rate of 80-99 or a rate >/= 120 were less likely to survive to hospital discharge compared to CC rate of 100-119. Adult OHCA study found CC rate was not associated with survival to hospital discharge. Pediatric in hospital arrest found CC rate < 100 associated with greater survival to hospital discharge compared to comparator.
ROSC:
Experimental: A swine model found CC rate of 80 had lower ROSC than CC rate of 100. A dog study found a CC rate of 60 had lower ROSC compared to a CC rate of 100. A model in newborn piglets found no difference in ROSC or in animals with CC rate of 90/min compared to animals that received 120/min.
Observational: In pediatric patients with OHCA, there was no difference in ROSC between patients receiving CC rate of 100-120 compared to other rates. In-hospital adult human CPR found higher odds of ROSC with rate of 121-140 compared to 100-120 or rate of > 140. Pediatric study of in hospital arrests found no difference in ROSC with CC rate different than comparator (100-120). Large study of OHCA patients had no difference in ROSC with with CC rate of 80-99 or > 120 cpm when compared to CC rate of 100-119. In a prospective veterinary study there was no difference in the median chest compression rate between patients with and without ROSC.
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