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BLS-17-v1
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RECOVER 2.0 Worksheet
QUESTION ID: BLS-17
PICO Question:
In cats and dogs in CPA (P), does interrupting a 2-minute cycle of chest compressions if ROSC is suspected (I), compared to not interrupting the 2-minute cycle (C), improve ... (O)?
Outcomes:
Favorable neurologic outcome, Complications, Survival to discharge, ROSC
Prioritized Outcomes (1= most critical; final number = least important):
- Favorable neurologic outcome
- Survival to Discharge
- ROSC
- Complications
Domain chairs: Steve Epstein, Kate Hopper; final edit by Jamie Burkitt
Evidence evaluators: Amanda Hilliard, Katie Gane
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, Survival to discharge, ROSC, Complications |
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PICO Question Summary
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Introduction |
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Minimizing interruptions in chest compressions (CCs) has been associated with improved outcomes (see BLS-16). A 2-minute CC cycle is recommended to optimize cardiac output but still allow pauses for patient assessment (see BLS-15). If ROSC is suspected during a 2-minute CC cycle the rescuers have the option of pausing CCs to determine if ROSC is present, or to complete the cycle and assess the patient at the scheduled pause. In human CPR guidelines for children and adults, no evidence was identified to assess this question as of 2020 and the treatment recommendation was to minimize interruptions in chest compressions and avoid pausing to evaluate circulation, without strong suspicion of ROSC.1
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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 addressing the PICO question.
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Treatment recommendation |
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We suggest interrupting a 2-minute CC cycle only when ROSC is suspected based on a combination of 1) a sudden and persistent increase in ETCO2 of great magnitude (e.g., by ≥ 10 mmHg to reach a value that is ≥ 35 mmHg) and 2) evidence of an arterial pulse distinct from chest compressions.(weak recommendation, expert opinion)
In the absence of capnography data, we recommend against interruption of a 2-minute CC cycle even if ROSC is suspected.(strong recommendation, expert opinion)
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Justification of treatment recommendation |
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Harm to patients undergoing CPR when not actually in cardiac arrest has been shown to be minimal,2 and hands-off time has been associated with non-survival. Additionally, a study in adults with nontraumatic OHCA found that a rise in ETCO2 of ≥ 10 mmHg was highly specific (97%, CI95 91% - 99%) though poorly sensitive for ROSC (33%, CI95 22% - 47%); specificity was 100% for people with non-cardiac causes of CPA (i.e., non-shockable rhythms).3 There is evidence in experimental pigs of significant and potentially clinically meaningful impairment of perfusion (arterial pressure, CoPP) when CC are administered to animals with a spontaneous heartbeat.4
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Knowledge gaps |
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There is no evidence regarding the interruption of 2-minute chest compression cycles in dogs and cats when ROSC is suspected.
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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. Lui CT, Poon KM, Tsui KL. Abrupt rise of end tidal carbon dioxide level was a specific but non-sensitive marker of return of spontaneous circulation in patient with out-of-hospital cardiac arrest. Resuscitation. 2016;104:53-58.
4. Xu J, Li C, Li Y, et al. Influence of Chest Compressions on Circulation during the Peri-Cardiac Arrest Period in Porcine Models. PLoS One. 2016;11(5):e0155212.
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