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BLS-16-v1
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RECOVER 2.0 Worksheet
QUESTION ID: BLS-16
PICO Question:
In cats and dogs in CPA (P), does taking a longer pause (e.g., 30 seconds) (I), compared to minimizing pauses between compression cycles (e.g., < 10 seconds) (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 edit by Jamie Burkitt
Evidence evaluators: Lisa Murphy, Anusha Balakrishnan
Conflicts of interest: none reported
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: Favorable neurologic outcome |
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0 |
N/A |
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Outcome: Survival to discharge |
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1 |
OBS |
0 |
- - |
0 |
0 |
+ |
+ |
0 |
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Human clinical study - modeling depicted a decrease in survival to hospital discharge of 14% for every 5-second increase in perishock pause interval up to 50 seconds. |
Low |
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1 |
EXP |
0 |
- - |
- |
0 |
+ |
0 |
0 |
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In a rodent model of ventricular fibrillation longer perishock pauses were associated with lower 24-h (but not 48-h) survival |
Very low |
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Outcome: ROSC |
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2 |
OBS |
0 |
- - |
0 |
0 |
+ |
0 |
0 |
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In two human observational studies of ventricular fibrillation, both found that longer peri-shock pauses were associated with decreased odds of ROSC. |
Very low |
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2 |
EXP |
0 |
- - |
- |
0 |
+ |
+ |
0 |
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In a rodent and swine model of ventricular fibrillation longer perishock pauses were associated with lower rates of ROSC |
Low |
PICO Question Summary
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Introduction |
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Maintaining high quality chest compressions (CCs) is considered essential for successful CPR but interruptions to CCs are required to perform ECG rhythm checks, defibrillation, and other clinical interventions. Pauses in CCs can lead to reductions in coronary and cerebral blood flow and lead to worse survival outcomes from CPR.1 The current human CPR guidelines emphasize minimizing the hands-off time and limiting peri-shock pauses to less than 10 seconds.2 There were no specific recommendations for duration of pause in CCs in the previous veterinary guidelines.3
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Consensus on science |
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For the most critical outcome of Favorable neurologic outcome, we identified no studies that address the PICO question.
Outcome 2: Survival to discharge
For the critical outcome of Survival to discharge, we found 1 observational study and 1 experimental study that address the PICO question. In the observational study in people, (Low quality of evidence, downgraded for very serious indirectness, upgraded for large magnitude of effect and for dose-response effect) that addresses the PICO question.4 Using log-linear modeling, this study in people with OHCA and a shockable rhythm showed a decrease in survival to hospital discharge of 14% for every 5-second increase in length of peri-shock pause up to 50 seconds.4 In an experimental rodent study (Very low quality of evidence, downgraded for very serious indirectness and serious imprecision, upgraded for large magnitude of effect), 25 rats underwent 4 minutes of fibrillatory arrest followed by 6 minutes of precordial compressions. Compressions were stopped and followed by a 0-,10-, 20-, 30-, or 40-second pause before electrical defibrillation. Survival to 24 hours was 80% for rats with immediate defibrillation, 40% for those with a 10-second pause prior to defibrillation, and 0% (P< 0.05 compared to immediate defibrillation) for those with 20-, 30-, or 40-second pauses prior to defibrillation; no significant difference in 48-hour survival was found among groups.5
Outcome 3: ROSC
For the critical outcome of ROSC, we identified 2 observational and 2 experimental studies that address the PICO question. The 2 observational studies were in adult people experiencing OHCA with shockable rhythms4,6 (very low quality of evidence, downgraded for very serious indirectness, upgraded for large magnitude of effect). In 35 adult people experiencing ventricular fibrillation, multivariate logistic regression analysis showed an adjusted odds ratio (95% CI) for ROSC of 13.07 (3.42–49.94) with a pre-shock interval of < 3 seconds and post shock interval of < 6 seconds (total pause < 9 seconds) compared to a total pause of ≥ 9 seconds.6 Using log-linear modeling, another study in 815 people with OHCA and a shockable rhythm showed the odds ratio (95% CI) of ROSC was 0.52 (0.27–0.97) with a peri-shock pause of ≥ 40 seconds compared to a peri-shock pause of < 20 seconds.4 Two experimental studies were identified, one in rodents and one in swine5,7 (low quality of evidence, downgraded for very serious indirectness and serious imprecision, upgraded for large magnitude of effect and for dose-response effect). In one study, 25 rats underwent 4 minutes of fibrillatory arrest followed by 6 minutes of precordial compressions. Compressions were stopped and followed by a 0-, 10-, 20-, 30-, or 40-second pause before electrical defibrillation. Following defibrillation, ROSC was achieved in 100%, 60%, 60%, 20% (P< 0.05 compared to immediate defibrillation) and 0% (P< 0.01 compared to immediate defibrillation) animals, respectively.5 In an experimental study including 60 pigs with a fibrillatory arrest model, a peri-shock pause in compressions of 40 seconds was associated with significantly worse ROSC than was a peri-shock pause between 0 and 20 seconds.7
Evidence (some available in 1965) 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 minimizing pauses between compression cycles (< 10 seconds) in dogs and cats during CPR.(strong recommendation, low quality of evidence)
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Justification of treatment recommendation |
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Evidence in multiple species in different settings show that the longer duration of pause in CCs, the less likely to achieve Survival or ROSC. It should be noted that all available data are in ventricular fibrillation arrest scenarios; however, the physiology occurring during pauses that would worsen outcome is likely similar regardless of ECG diagnosis and support minimizing pause duration. In addition, higher CC fractions during CPR (i.e., minimizing hands-off time - not specifically addressed in this PICO question) have been associated with improved outcomes.8 Minimizing pause duration increases CC fraction, which lends additional support to the treatment recommendation.
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Knowledge gaps |
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The ideal CC pause duration during which to evaluate the ECG during CPR in dogs and cats is unknown.
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1. Brouwer TF, Walker RG, Chapman FW, Koster RW. Association Between Chest Compression Interruptions and Clinical Outcomes of Ventricular Fibrillation Out-of-Hospital Cardiac Arrest. Circulation. 2015;132(11):1030-1037.
2. 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.
3. 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.
4. Cheskes S, Schmicker RH, Christenson J, et al. Perishock pause: an independent predictor of survival from out-of-hospital shockable cardiac arrest. Circulation. 2011;124(1):58-66.
5. Sato Y, Weil MH, Sun S, et al. Adverse effects of interrupting precordial compression during cardiopulmonary resuscitation. Crit Care Med. 1997;25(5):733-736.
6. Sell RE, Sarno R, Lawrence B, et al. Minimizing pre- and post-defibrillation pauses increases the likelihood of return of spontaneous circulation (ROSC). Resuscitation. 2010;81(7):822-825.
7. Walcott GP, Melnick SB, Walker RG, et al. Effect of timing and duration of a single chest compression pause on short-term survival following prolonged ventricular fibrillation. Resuscitation. 2009;80(4):458-462.
8. Berg RA, Sanders AB, Kern KB, et al. Adverse hemodynamic effects of interrupting chest compressions for rescue breathing during cardiopulmonary resuscitation for ventricular fibrillation cardiac arrest. Circulation. 2001;104(20):2465-2470.
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