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ALS-05-v1
1 General Document comment
0 Sentence and Paragraph comments
0 Image and Video comments
1 RECOVER 2.0 Worksheet
2 QUESTION ID: ALS-05
3
PICO Question:
In dogs with CPA (P) does closed-chest CPR (I) compared to open chest CPR (C) improve outcome (O)?
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Outcomes:
Favorable neurologic outcome,Surrogate marker(s) of perfusion,Survival to Discharge,ROSC
5 Prioritized Outcomes (1= most critical; final number = least important):
- 6 Favorable neurologic outcome
- 7 Survival to discharge
- 8 ROSC
- 9 Surrogate markers of perfusion
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Domain chairs: Gareth Buckley, Elizabeth Rozanski, Jake Wolf
11 Evidence evaluators: Elizabeth Ross, Stefania Grasso,Melissa Evans
12 Conflicts of interest: None
13 Search strategy: See attached document
14 Evidence Review:
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15 Study Design |
16 Reduced Quality Factors
17 0 = no serious, - = serious,
18 - - = very serious |
19 Positive Quality Factors
20 0 = none, + = one, ++ = multiple |
21 Dichotomous Outcome Summary |
22 Non-Dichotomous Outcome Summary
23 Brief description |
24 Overall Quality
25
High, moderate, low, |
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26 No of studies |
27 Study Type |
28 RoB |
29 Indirectness |
30 Imprecision |
31 Inconsistency |
32 Large Effect |
33 Dose-Response |
34 Confounder |
35 # Intervention with Outcome |
36 # Control with Outcome |
37 RR (95% CI) |
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38 Outcome: Favorable neurologic outcome |
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39 0 |
40 CT |
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41 1 |
42 OB |
43 - |
44 – |
45 0 |
46 0 |
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47 CPA after cardiac surgery - all survived |
48 Very low |
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49 3 |
50 ES |
51 0 |
52 0 |
53 - |
54 - |
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55 Improved neuro outcome with open chest CPR |
56 Very low |
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57 Outcome: Survival to discharge |
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58 0 |
59 CT |
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60 5 |
61 OB |
62 - |
63 - |
64 0 |
65 0 |
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66 Equivocal whether improved survival |
67 Very low |
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68 4 |
69 ES |
70 0 |
71 0 |
72 - |
73 - |
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74 Improved survival with early open chest |
75 Moderate |
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76 Outcome: ROSC |
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77 0 |
78 CT |
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79 3 |
80 OB |
81 – |
82 – |
83 0 |
84 0 |
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85 No difference with open chest CPR |
86 Very low |
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87 4 |
88 ES |
89 0 |
90 0 |
91 - |
92 - |
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93 Improved ROSC in dogs with open chest |
94 Very low |
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95 Outcome: Surrogate markers of perfusion |
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96 0 |
97 CT |
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98 1 |
99 OB |
100 – |
101 – |
102 0 |
103 0 |
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104 No difference in ETCO2 with open chest |
105 Very low |
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106 14 |
107 ES |
108 0 |
109 0 |
110 0 |
111 - |
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112 Improved hemodynamics with open chest |
113 Low |
114 PICO Question Summary
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115 Introduction |
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116 The 2012 RECOVER veterinary CPR guidelines advise prompt open-chest CPR (OCCPR) in specific clinical scenarios, including tension pneumothorax and pericardial effusion.1 In human medicine, emergency department thoracotomy (EDT) may be used for cardiac arrest secondary to penetrating trauma.2 However, the utility and timing of OCCPR outside these specific situations is unknown, particularly considering the cost of OCCPR and the intensity of subsequent management.
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117 Consensus on science |
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118 Outcome 1: Favorable neurologic outcome
119 For the most critical outcome of favorable neurologic outcome, one observational study in human adults (very low quality of evidence downgraded for serious risk of bias and indirectness) and three experimental studies in dogs were identified (very low quality of evidence downgraded for serious imprecision and inconsistency).3–6
120 A study by Kern et al. (1987) examined 29 mongrel dogs with induced ventricular fibrillation that received standard CPR for 15 minutes and subsequent defibrillation. Unsuccessfully defibrillated dogs were then randomized to receive 2 minutes of either OCCPR or CCCPR. The study showed no difference in neurological scores between the two groups.4 In another study in dogs with ventricular fibrillation and immediate defibrillation or 30 subsequent minutes of CCCPR or OCCPR, the authors found that OCCPR resulted in improved neurological scores when compared to CCCPR.5 In 12 dogs with cardiac arrest induced via potassium chloride that were then randomized to either OCCPR or CCCPR, all dogs with OCCPR were resuscitated and behaved normally at 72 hours.6 Only 3/7 of CCPCR dogs survived and 2 of these had incapacitating neurological deficits.
121 Anthi et al. (1998) examined 29 human adults with cardiac arrest within 24 hours following cardiac surgery.3 In this population, CCCPR was performed for 3-5 minutes, then followed by OCCPR if needed. Thirteen people achieved ROSC with CCCPR and 14 achieved ROSC with OCCPR; all were discharged neurologically intact. However, no control population was used to compare OCCPR to CCCPR directly.
122 Outcomes 2 and 3: Survival to discharge and ROSC
123 For the next most critical outcomes of survival to discharge and ROSC, five observational studies in addition to the Anthi study described above were identified in people (four in adults, one in children) with traumatic cardiac arrest (very low quality of evidence downgraded for serious risk of bias and indirectness).2,3,7–10 Four experimental studies were also identified for these outcomes, all in previously healthy dogs (very low quality of evidence, downgraded for serious imprecision and inconsistency).4–6,11 The observational studies in people demonstrated little to no benefit with open-chest CPR (OCCPR) when compared to closed-chest CPR (CCCPR), while the experimental studies in dogs largely demonstrated improved survival with OCCPR.
124 The Kern et al. study of 29 mongrel dogs with induced ventricular fibrillation showed improved ROSC frequency, 24-hour survival (12/14 v. 4/14), and 7-day survival (11/14 v. 4/14) with OCCPR.4 Similarly, the Bircher et al. study found that OCCPR resulted in improved frequency of ROSC and survival at 24 hours compared to CCCPR.5 As described above, Benson et al. found in 12 dogs with cardiac arrest induced via potassium chloride that all dogs with OCCPR were resuscitated and survived to 72 hours, while only 3/7 of CCCPR dogs achieved ROSC.6 DeBehnke et al. (1991) found in a myocardial infarct model in 26 dogs with subsequent ventricular fibrillation that there was no difference in ROSC or survival between dogs receiving OCCPR and those receiving CCCPR.11
125 Schulz-Drost et al. (2020) examined adults who underwent emergency department thoracotomy (EDT) for trauma, a subset of whom underwent EDT for cardiac arrest.2 For these, the survival rate was 4.8% for blunt trauma but was 20.7% for penetrating trauma. Prieto et al. (2020) analyzed patients 16 years or younger who underwent EDT within 30 minutes of arrival to a hospital.8 Of the 53 patients with no signs of life who received EDT, none survived. In a retrospective study of patients with blunt trauma undergoing CPR in the emergency department, Endo et al. (2017) found higher survival to discharge for CCCPR (3.6% v. 1.8%) and 24 hour survival (9.6% v. 5.6%) when compared to OCCPR.9 With propensity matching, significantly lower odds of survival to discharge and survival at 24 hours were found with OCCPR. However, it was difficult to determine why OCCPR was initiated in patients and made it challenging to compare the two groups. In a later study, Endo et al. (2020) found that OCCPR was associated with survival to discharge in trauma patients with signs of life upon hospital arrival when compared to CCCPR (15.2% v. 11.7%).10 This association persisted during logistic regression analysis and propensity score matching.
126 Outcome 4: Surrogate markers of perfusion
127 While it was not the most critical outcome examined, there have been numerous experimental studies in dogs evaluating surrogate markers of perfusion with OCCPR, many of which suggest a benefit over CCCPR (low quality of evidence, downgraded for serious imprecision). Many studies in dogs with induced ventricular fibrillation found higher arterial pressures, carotid blood flow, cardiac output, cerebral perfusion, and/or coronary perfusion pressure in OCCPR compared to CCCPR.4,5,11–16 Kern et al. (1991) demonstrated that OCCPR after 40 minutes of ventricular fibrillation in dogs resulted in better arterial pressures and coronary perfusion than CCCPR after 20 minutes of ventricular fibrillation.17 Weiser et al. (1962) found that average cardiac output was significantly higher in OCCPR (55%) when compared to CCCPR (22%).18 The difference in cardiac output between OCCPR and CCCPR was particularly pronounced in dogs greater than 10 kg. In a study by Rieder et al. (1985) of 10 dogs in which cardiac arrest was induced via potassium chloride induction while undergoing a laparotomy, OCCPR resulted in significantly higher cardiac index, MAP, and carotid blood flow when compared to CCCPR.19 A transdiaphragmatic approach in which one hand through the diaphragm compressed the heart against the sternum while the other hand compressed the sternum externally resulted in optimal hemodynamics over other techniques. Two additional studies demonstrated reduced brain injury via histopathological examination with OCCPR when compared with CCCPR.6,20 |
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128 Treatment recommendation |
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129 We recommend open-chest CPR (OCCPR) in dogs and cats with abdominal organs or substantial accumulations of fluid or air in the pleural or pericardial spaces (strong recommendation, expert opinion).
130 We recommend direct cardiac massage in dogs and cats undergoing abdominal or thoracic surgery (strong recommendation, low quality of evidence).
131 We suggest OCCPR in dogs and cats with penetrating thoracic trauma or rib fractures at or near the chest compression point (weak recommendation, very low quality of evidence).
132 In medium and large-breed round-chested and wide-chested dogs in which OCCPR is feasible and clients are amenable to the procedure, we recommend that CCCPR be started immediately and OCCPR be started as soon as possible (strong recommendation, low quality of evidence)
133 We suggest not attempting OCCPR in cats and small dogs (< 15kg) that do not have pleural or pericardial disease, penetrating thoracic trauma or are not undergoing abdominal or thoracic surgery (weak recommendation, expert opinion)
134 We recommend discussing the pros and cons of OCCPR in any dog at risk of CPA and obtaining a “CPR code” at the time of hospitalization if OCCPR is offered by the practice and is indicated. (strong recommendation, expert opinion) |
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135 Justification of treatment recommendation |
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136 Many but not all experimental studies in dogs demonstrated improved neurologic outcome, survival, ROSC, and hemodynamics with open-chest CPR (OCCPR) when compared to closed-chest CPR (CCCPR). These findings were especially profound for large dogs and dogs already undergoing laparotomy. The recommendation is complicated, however, by observational studies in people that have largely failed to demonstrate a benefit with OCCPR when compared to CCCPR. Given the positive results in the experimental studies in dogs, the committee recommends OCCPR as soon as possible in medium to large breed round-chested or wide-chested dogs in which OCCPR is feasible. Factors that could reduce feasibility of OCCPR in medium and large round-chested and wide-chested dogs include owner consent, local practice limitations that would limit the required post-ROSC care, and rescuer OCCPR procedure competence. In addition, considering the likely increased efficacy of CCCPR in keel-chested medium and large breed dogs, the committee thinks it is reasonable to default to CCCPR in these patients. Although outcomes are better with OCCPR in this subset of animals, the committee recognizes that even in practices with the skill set and facilities required for the procedure, it is likely that OCCCPR will continue to be a rarely performed procedure due to the invasiveness, client preference, and intensive after-care required. Given the likely futility of CCCPR in dogs and cats with pleural or pericardial fluid, air or abdominal organ displacement and the lack of feasibility of closed chest compressions in dogs and cats that arrest during laparotomy or thoracotomy, a stronger recommendation for OCCPR is made in these circumstances.
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137 Knowledge gaps |
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138 The optimal timing for intervention with open-chest CPR (OCCPR) for dogs and cats with cardiopulmonary arrest is unknown. It is unknown at what weight OCCPR should be considered as a primary intervention in dogs with cardiopulmonary arrest. The diseases for which OCCPR should be considered in dogs and cats are poorly described. The appropriate time to intervene with OCCPR in dogs and cats with cardiopulmonary arrest is considered a high-priority knowledge gap in the veterinary literature.
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139 References:
140 1. Fletcher DJ, Militello R, Schoeffler GL, Rogers CL. Development and evaluation of a high-fidelity canine patient simulator for veterinary clinical training. J Vet Med Educ. 2012;39(1):7-12.
141 2. Schulz-Drost S, Merschin D, Gümbel D, et al. Emergency department thoracotomy of severely injured patients: an analysis of the TraumaRegister DGU(®). Eur J Trauma Emerg Surg. 2020;46(3):473-485.
142 3. Anthi A, Tzelepis GE, Alivizatos P, Michalis A, Palatianos GM, Geroulanos S. Unexpected cardiac arrest after cardiac surgery: incidence, predisposing causes, and outcome of open chest cardiopulmonary resuscitation. Chest. 1998;113(1):15-19.
143 4. Kern KB, Sanders AB, Badylak SF, et al. Long-term survival with open-chest cardiac massage after ineffective closed-chest compression in a canine preparation. Circulation. 1987;75(2):498-503.
144 5. Bircher N, Safar P. Cerebral preservation during cardiopulmonary resuscitation. Crit Care Med. 1985;13(3):185-190.
145 6. Benson DM, O’Neil B, Kakish E, et al. Open-chest CPR improves survival and neurologic outcome following cardiac arrest. Resuscitation. 2005;64(2):209-217.
146 7. Suzuki K, Inoue S, Morita S, et al. Comparative Effectiveness of Emergency Resuscitative Thoracotomy versus Closed Chest Compressions among Patients with Critical Blunt Trauma: A Nationwide Cohort Study in Japan. PLoS One. 2016;11(1):e0145963.
147 8. Prieto JM, Van Gent JM, Calvo RY, et al. Nationwide analysis of resuscitative thoracotomy in pediatric trauma: Time to differentiate from adult guidelines? J Trauma Acute Care Surg. 2020;89(4):686-690.
148 9. Endo A, Shiraishi A, Otomo Y, Tomita M, Matsui H, Murata K. Open-chest versus closed-chest cardiopulmonary resuscitation in blunt trauma: analysis of a nationwide trauma registry. Crit Care. 2017;21(1):169.
149 10. Endo A, Kojima M, Hong ZJ, Otomo Y, Coimbra R. Open-chest versus closed-chest cardiopulmonary resuscitation in trauma patients with signs of life upon hospital arrival: a retrospective multicenter study. Crit Care. 2020;24(1):541.
150 11. DeBehnke DJ, Angelos MG, Leasure JE. Comparison of standard external CPR, open-chest CPR, and cardiopulmonary bypass in a canine myocardial infarct model. Ann Emerg Med. 1991;20(7):754-760.
151 12. Arai T, Dote K, Tsukahara I, Nitta K, Nagaro T. Cerebral blood flow during conventional, new and open-chest cardio-pulmonary resuscitation in dogs. Resuscitation. 1984;12(2):147-154.
152 13. Bircher N, Safar P, Stewart R. A comparison of standard, “MAST”-augmented, and open-chest CPR in dogs. A preliminary investigation. Crit Care Med. 1980;8(3):147-152.
153 14. Barsan WG, Levy RC. Experimental design for study of cardiopulmonary resuscitation in dogs. Ann Emerg Med. 1981;10(3):135-137.
154 15. Sanders AB, Kern KB, Ewy GA, Atlas M, Bailey L. Improved resuscitation from cardiac arrest with open-chest massage. Annals of Emergency Medicine. 1984;13(9 PART 1):672-675.
155 16. Fleisher G, Sagy M, Swedlow DB, Belani K. Open- versus closed-chest cardiac compressions in a canine model of pediatric cardiopulmonary resuscitation. Am J Emerg Med. 1985;3(4):305-310.
156 17. Kern KB, Sanders AB, Janas W, et al. Limitations of open-chest cardiac massage after prolonged, untreated cardiac arrest in dogs. Annals of Emergency Medicine. 1991;20(7):761-767.
157 18. Weiser FM, Adler LN, Kuhn LA. Hemodynamic effects of closed and open chest cardiac resuscitation in normal dogs and those with acute myocardial infarction. The American Journal of Cardiology. 1962;10(4):555-561.
158 19. Rieder CF, Crawford BG, Iliopoulos JI, Thomas JH, Pierce GE, Hermreck AS. A study of the techniques of cardiac massage with the abdomen open. Surgery. 1985;98(4):824-830.
159 20. Badylak SF, Kern KB, Tacker WA, Ewy GA, Janas W, Carter A. The comparative pathology of open chest vs. mechanical closed chest cardiopulmonary resuscitation in dogs. Resuscitation. 1986;13(4):249-264.
160 Supplemental:
161 Outcome: Favorable neurologic outcome
162 0 Clinical Trials
163 1 Observational studies
164 Anthi (1998): Unexpected cardiac arrest after cardiac surgery
165 ● 29 patients with cardiac arrest within 24 hours after cardiac surgery
166 ● Closed chest CPR performed initially for 3-5 min, then followed by open chest CPR if needed
167 ● 13 resuscitated with closed chest, 14 with open chest
168 ● All discharged neurologically intact
169 3 Experimental studies
170 Kern (1987): Long term survival with open chest cardiac massage after ineffective closed chest compression in a canine preparation
171 ● Ventricular fibrillation induced in 29 mongrel dogs and after 3 min, standard CPR was initiated (using a machine)
172 ● Defibrillation attempted twice after 15 min of fibrillation
173 ● Unsuccessfully defibrillated animals randomized to receive 2 min of closed chest or 2 min of open chest
174 ● Improved ROSC, 24 hour survival, and 7 day survival with open chest. No difference in neurological scores though small population may have limited findings
175 Bircher (1985): Cerebral preservation during CPR
176 ● Ventricular fibrillation in 32 dogs for 4 minutes
177 ● Subdivided into four groups: immediate defibrillation; 30 min of standard CPR, simultaneous ventilation compression CPR, open chest CPR
178 ● After 30 min, drug therapy and defibrillation attempted
179 ● Control: ROSC in all and nearly normal neuro deficit scores at 24 hours
180 ● Standard: 6/8 restored and ⅝ had severe neuro damage and did not survive 24 hours
181 ● SVC: ⅝ ROSC, but all brain dead and none survived 24 hours
182 ● Open chest: 7 survived 24 hours and neuro scores not significantly different from control group
183 Benson (2005): Open chest CPR improves survival and neurologic outcome following cardiac arrest
184 ● Cardiac arrest induced via KCl in 12 dogs. Received 5 min of non-intervention and then randomized to receive either closed or open chest CPR for 15 min and were then resuscitated.
185 ● All open chest CPR dogs resuscitated and behaviorally normal at 72 hours. Only 3/7 closed chest CPR dogs survived and 2 had incapacitating deficits.
186 ● Neuro score did include those who died in the closed chest group which may have swayed results
187 Outcome: Survival to discharge
188 0 Clinical Trials
189 5 Observational studies
190 Schulz-Drost (2020): Emergency department thoracotomy of severely injured patients: an analysis of the TraumaRegister DGU
191 ● Focus was on all ED thoracotomy but a subset underwent EDT for cardiac arrest
192 ● For these, survival rate of 4.8% with blunt trauma but 20.7% for penetrating trauma with EDT
193 Suzuki (2016): Comparative effectiveness of emergency resuscitative thoracotomy versus closed chest compressions among patients with critical blunt trauma: a nationwide cohort study in Japan
194 ● Retrospective study from Japan in which 1377 blunt trauma patients who received CPR in the ED or OR. 484 received emergency resuscitative thoracotomy and 893 received closed chest CPR
195 ● Lower survival with open chest (4.5% v 17.5%) and 28 day survival (1.2% v 6%). This was independently associated on multivariable analysis
196 Prieto (2020): Nationwide analysis of resuscitative thoracotomy in pediatric trauma: time to differentiate from adult guidelines?
197 ● Retrospective analysis of patients 16 years or younger who underwent EDT within 30 minutes of arrival in US database
198 ● 53 patients with no signs of life at presentation and received EDT, none of whom survived
199 Endo (2017): Open chest versus closed chest CPR in blunt trauma: analysis of a nationwide trauma registry
200 ● Retrospective study for patients with blunt trauma and undergoing CPR in an ED divided into open and closed chest groups
201 ● 6510 patients (2192 open chest, 4318 closed chest) analyzed
202 ● Higher survival in closed chest at 24 hours (9.6% v 5.6%) and in hospital survival (3.6% v 1.8%)
203 ● With propensity matching, significantly lower odds of survival to hospital discharge for open chest CPR and survival over 24 hours
204 ● However, difficult to determine why open chest was initiated making it difficult to compare these two groups and application of open chest differed significantly based on hospital
205 Endo (2020): Open chest versus closed chest CPR in trauma patients with signs of life upon hospital arrival: a retrospective multicenter study
206 ● Retrospective cohort study in USA with severe trauma patients who had SOL upon arrival and received CPR within first 6 hours of ED admission
207 ● 2682 patients found (1032 open chest, 1650 closed chest). Open chest associated with survival to discharge (15.2% v 11.7%), including for logistic regression analysis and propensity score matching analysis
208 4 Experimental studies
209 Kern (1987): Long term survival with open chest cardiac massage after ineffective closed chest compression in a canine preparation
210 ● Ventricular fibrillation induced in 29 mongrel dogs and after 3 min, standard CPR was initiated (using a machine)
211 ● Defibrillation attempted twice after 15 min of fibrillation
212 ● Unsuccessfully defibrillated animals randomized to receive 2 min of closed chest or 2 min of open chest
213 ● Improved ROSC, 24 hour survival (12/14 v 4/14), and 7 day survival (11/14 v 4/14) with open chest.
214 Benson (2005): Open chest CPR improves survival and neurologic outcome following cardiac arrest
215 ● Cardiac arrest induced via KCl in 12 dogs. Received 5 min of non-intervention and then randomized to receive either closed or open chest CPR for 15 min and were then resuscitated.
216 ● All open chest CPR dogs resuscitated and behaviorally normal at 72 hours. Only 3/7 closed chest CPR dogs survived and 2 had incapacitating deficits.
217 DeBehnke (1991): Comparison of standard external CPR, open chest CPR, and cardiopulmonary bypass in a canine myocardial infarct model
218 ● 26 dogs received left anterior descending coronary artery occlusion followed by four minutes of ventricular fibrillation and eight minutes of mechanical CPR. At 12 minutes, randomized to one of three groups: open chest CPR, cardiopulmonary bypass, or standard closed chest CPR
219 ● ROSC in 9/9 bypass, 2/8 closed chest, and 6/9 open chest CPR
220 ● Survival to four hours in 3/9 bypass and open chest and 2/8 closed chest. No difference in survival
221 Kern (1991): Limitations of open chest cardiac massage after prolonged, untreated cardiac arrest in dogs
222 ● 20 mongrel dogs with 10, 20, or 40 minutes of untreated ventricular fibrillation. Open chest CPR compared to closed chest CPR for those that did not respond to initial defibrillation. Defibrillation performed every 3 minutes (closed chest received external and open chest received internal)
223 ● Animal considered resuscitated after 12 min if systolic BP > 40 mmHg
224 ● Open chest better for ROSC (5/5 v ⅕) after 20 min of vfib. No ROSC with open chest after 40 min
225 ● Poor survival if open chest initiated following 20 or more minutes of untreated cardiac arrest (⅘ survived if began after 10 untreated minutes, ⅕ if after 20 minutes)
226 Outcome: ROSC
227 0 Clinical Trials
228 3 Observational studies
229 Bradley (2016): Open chest cardiac massage offers no benefit over closed chest compressions in patients with traumatic cardiac arrest
230 ● Prospective observational study that enrolled patients with traumatic cardiac arrest. Enrolled 33 patients (16 open, 17 closed).
231 ● No difference in ROSC between groups, but couldn’t control for confounders
232 DiGiacomo (2017): Thoracotomy in the ED for resuscitation of the mortally injured
233 ● Retrospective of all patients who underwent ED RT as an adjunct to resuscitation. No control group
234 ● 68 patients identified, 27 of whom achieved ROSC
235 ● Patients without signs of life at the scene who arrived without signs of life did not respond to EDRT
236 ● Only one long term survivor who had mild cognitive deficits
237 Anthi (1998): Unexpected cardiac arrest after cardiac surgery
238 ● 29 patients with cardiac arrest within 24 hours after cardiac surgery
239 ● Closed chest CPR performed initially for 3-5 min, then followed by open chest CPR if needed
240 ● 13 resuscitated with closed chest, 14 with open chest
241 ● All discharged neurologically intact
242 ● No control group to determine if ROSC would have been successful with longer closed chest CPR
243 7 Experimental studies
244 Kern (1987): Long term survival with open chest cardiac massage after ineffective closed chest compression in a canine preparation
245 ● Ventricular fibrillation induced in 29 mongrel dogs and after 3 min, standard CPR was initiated (using a machine)
246 ● Defibrillation attempted twice after 15 min of fibrillation
247 ● Unsuccessfully defibrillated animals randomized to receive 2 min of closed chest or 2 min of open chest
248 ● Improved ROSC (14/14 v 5/14), 24 hour survival (12/14 v 4/14), and 7 day survival (11/14 v 4/14) with open chest.
249 Badylak (1986): The comparative pathology of open chest vs mechanical closed chest CPR in dogs
250 ● VF induced in 28 healthy mongrel dogs, no treatment for 3 min, then mechanical closed chest CPR given for 12 min, followed by defibrillation twice
251 ● Then. 2 groups: closed chest or open chest CPR with ALS
252 ● ROSC and survival to euthanasia at 7 days: 4/14 with closed chest, 11/14 with open chest
253 Benson (2005): Open chest CPR improves survival and neurologic outcome following cardiac arrest
254 ● Cardiac arrest induced via KCl in 12 dogs. Received 5 min of non-intervention and then randomized to receive either closed or open chest CPR for 15 min and were then resuscitated.
255 ● All open chest CPR dogs resuscitated and behaviorally normal at 72 hours. Only 3/7 closed chest CPR achieved ROSC and 2 had incapacitating deficits.
256 Kern (1991): Limitations of open chest cardiac massage after prolonged, untreated cardiac arrest in dogs
257 ● 20 mongrel dogs with 10, 20, or 40 minutes of untreated ventricular fibrillation. Open chest CPR compared to closed chest CPR for those that did not respond to initial defibrillation. Defibrillation performed every 3 minutes (closed chest received external and open chest received internal)
258 ● Animal considered resuscitated after 12 min if systolic BP > 40 mmHg
259 ● Open chest better for ROSC (5/5 v ⅕) after 20 min of vfib. No ROSC with open chest after 40 min
260 DeBehnke (1991): Comparison of standard external CPR, open chest CPR, and cardiopulmonary bypass in a canine myocardial infarct model
261 ● 26 dogs received left anterior descending coronary artery occlusion follwed by four minutes of ventricular fibrillation and eight minutes of mechanical CPR. At 12 minutes, randomized to one of three groups: open chest CPR, cardiopulmonary bypass, or standard closed chest CPR
262 ● ROSC in 9/9 bypass, 2/8 closed chest, and 6/9 open chest CPR
263 Sanders (1984): Improved resuscitation from cardiac arrest with open-chest massage
264 ● 10 mongrel dogs were fibrillated. CPR was initiated and continued for 15 minutes. Patients with coronary perfusion pressures <30 mmHg were then excluded (no dogs fell into this category)
265 ● Half of the remaining underwent open chest CPR and half underwent closed chest CPR. They were all then defibrillated at 19 minutes
266 ● 0/5 in closed chest achieved ROSC, ⅘ with open chest achieved ROSC
267 Bircher (1985): Cerebral preservation during CPR
268 ● Ventricular fibrillation in 32 dogs for 4 minutes
269 ● Subdivided into four groups: immediate defibrillation; 30 min of standard CPR, simultaneous ventilation compression CPR, open chest CPR
270 ● After 30 min, drug therapy and defibrillation attempted
271 ● Control: ROSC in all and nearly normal neuro deficit scores at 24 hours
272 ● Standard: 6/8 restored and ⅝ had severe neuro damage and did not survive 24 hours
273 ● SVC: ⅝ ROSC, but all brain dead and none survived 24 hours
274 Outcome: Surrogate markers of perfusion
275 0 Clinical Trials
276 1 Observational studies
277 Bradley (2016): Open chest cardiac massage offers no benefit over closed chest compressions in patients with traumatic cardiac arrest
278 ● Prospective observational study that enrolled patients with traumatic cardiac arrest. Enrolled 33 patients (16 open, 17 closed).
279 ● No difference in ROSC between groups, but couldn’t control for confounders
280 ● With time matched comparisons, ETCO2 was not different for initial, final, peak, mean, or median values between open and closed chest
281 14 Experimental studies
282 Arai (1984): Cerebral blood flow during conventional, new, and open chest CPR in dogs
283 ● VF induced in 15 dogs. Chest compressions and ventilation were done manually (by one individual). Closed chest CPR was initiated for 30 seconds, then new CPR (chest compressions with high airway pressure ventilation) for 30 seconds. This was attempted 3 times and then open chest CPR was initiated
284 ● Open chest had highest MAP, carotid blood flow, and CPP, along with sinus blood flow. No difference between closed and new CPR
285 Bircher (1985): Cerebral preservation during CPR
286 ● Ventricular fibrillation in 32 dogs for 4 minutes
287 ● Subdivided into four groups: immediate defibrillation; 30 min of standard CPR, simultaneous ventilation compression CPR, open chest CPR
288 ● After 30 min, drug therapy and defibrillation attempted
289 ● Highest MAP and lower CVP than other groups
290 Redding (1961): A comparison of open chest and closed chest cardiac massage in dogs
291 ● VF induced in 20 healthy mongrel dogs. 30 seconds later, closed chest initiated in 10 dogs and open chest for 10 minutes for 20 minutes, followed by defibrillation
292 ● Similar aortic and carotid flow between groups but stats not performed
293 Bircher (1980): A comparison of standard, MAST augmented, and open chest CPR in dogs
294 ● VF induced in 9 dogs. Closed chest CPR initiated after 2 min of VF. After 2 hours, open chest CPR attempted
295 ● Open chest significantly increased arterial and perfusion pressures and more than doubled common carotid arterial blood flow
296 Rieder (1985): A study of the techniques of cardiac massage with the abdomen open
297 ● 10 mongrel dogs were anesthetized and had a midline laparotomy performed. KCl was administered to cause CPA
298 ● Closed chest CPR was initiated in lateral recumbency. Six cardiac compression techniques were then trialed
299 ● Highest CI, MAP, and Carotid blood flow with transdiaphragmatic retrocardiac massage (compression of the heart against the sternum with one hand through the diaphragm). Significantly better than closed chest
300 DeBehnke (1991): Comparison of standard external CPR, open chest CPR, and cardiopulmonary bypass in a canine myocardial infarct model
301 ● 26 dogs received left anterior descending coronary artery occlusion follwed by four minutes of ventricular fibrillation and eight minutes of mechanical CPR. At 12 minutes, randomized to one of three groups: open chest CPR, cardiopulmonary bypass, or standard closed chest CPR
302 ● Coronary perfusion pressure significantly higher with bypass and open chest compared to closed chest
303 ● Ratio of necrotic to ischemic myocardium at 4 hours lower with bypass and open chest than closed chest
304 Barsan (1981): Experimental design for study of CPR in dogs
305 ● 13 mongrel dogs with induced VF were divided into three groups: 1) 30 seconds of VF followed by closed chest compressions (n=2) 2) 2 dogs with automatic gas powered chest compressor and 3) 9 dogs with open chest (4 with left thoracotomy, 5 with median sternotomy)
306 ● External CO approximately 17% while internal averaged 35% and also had a higher average systolic blood pressure (approximately 50 v 80 mmHg)
307 Weiser (1962): Hemodynamic effects of closed and open chest cardiac resuscitation in normal dogs and those with acute myocardial infarction
308 ● 22 mongrel dogs anesthetized and divided into two groups: 12 normal and 10 induced myocardial infarction
309 ● VF induced in those that did not develop it. Group A: 15 seconds of VF followed by closed chest for 5 min, followed by open chest compression
310 ● Group B: 7 with only open, 1 closed then open, 2 only closed
311 ● CO averaged 22% with closed chest and 55% in open chest. CO significantly higher once converted to open in dogs that had both procedures
312 ● In dogs <10 kg, closed chest averaged CO of 39% while >10 kg was 13% and 75% for open chest for <10 kg and 49% for open chest for > 10 kg
313 Sanders (1984): Improved resuscitation from cardiac arrest with open-chest massage
314 ● 10 mongrel dogs were fibrillated. CPR was initiated and continued for 15 minutes. Patients with coronary perfusion pressures <30 mmHg were then excluded (no dogs fell into this category)
315 ● Half of the remaining underwent open chest CPR and half underwent closed chest CPR. They were all then defibrillated at 19 minutes
316 ● Aortic and coronary perfusion pressures significantly higher with open chest within the first 2 minutes
317 Kern (1991): Limitations of open chest cardiac massage after prolonged, untreated cardiac arrest in dogs
318 ● 20 mongrel dogs with 10, 20, or 40 minutes of untreated ventricular fibrillation. Open chest CPR compared to closed chest CPR for those that did not respond to initial defibrillation. Defibrillation performed every 3 minutes (closed chest received external and open chest received internal)
319 ● Animal considered resuscitated after 12 min if systolic BP > 40 mmHg
320 ● Open chest significantly increased aortic systolic and diastolic pressures and increased RAP, as well as coronary perfusion pressure
321 ● Open chest at 40 minutes of VF provided better SAP and DAP and CPP than 20 minutes of VF followed by closed chest
322 Kern (1987): Long term survival with open chest cardiac massage after ineffective closed chest compression in a canine preparation
323 ● Ventricular fibrillation induced in 29 mongrel dogs and after 3 min, standard CPR was initiated (using a machine)
324 ● Defibrillation attempted twice after 15 min of fibrillation
325 ● Unsuccessfully defibrillated animals randomized to receive 2 min of closed chest or 2 min of open chest
326 ● Open chest: significantly increased SAP, DAP, CPP
327 Fleisher (1985): Open versus closed chest cardiac compression in a canine model of pediatric CPR
328 ● 6-12 week old puppies who were 2-8 kg in weight were used. CPA induced with KCl and allowed for 3 minutes. CPR then initiated with open or closed chest CPR (5 in each group)
329 ● Open chest produced greater CO and higher cerebral blood flow but no difference in SAP
330 ● Closed chest: ⅗ experienced liver lacerations
331 Benson (2005): Open chest CPR improves survival and neurologic outcome following cardiac arrest
332 ● Cardiac arrest induced via KCl in 12 dogs. Received 5 min of non-intervention and then randomized to receive either closed or open chest CPR for 15 min and were then resuscitated.
333 ● All open chest CPR dogs resuscitated and behaviorally normal at 72 hours. Only 3/7 closed chest CPR dogs survived and 2 had incapacitating deficits.
334 ● Histology of survivors for open chest showed little to no injury of the brain, histology of survivors of closed chest revealed moderate to severe lesions
335 Badylak (1986): The comparative pathology of open chest vs mechanical closed chest CPR in dogs
336 ● VF induced in 28 healthy mongrel dogs, no treatment for 3 min, then mechanical closed chest CPR given for 12 min, followed by defibrillation twice
337 ● Then. 2 groups: closed chest or open chest CPR with ALS
338 ● Open chest caused more severe histopath scores to skin, chest wall muscle, SC tissues, and pleura, but lower scores for the brain
General Document Comments 1
As written it implies you would never do OCCPR in a animals < 15kg if no other listed factors present. While I would agree we would not recommend starting CPR with open chest in this population, it seems possible that there could be consideration of OCCPR in these animals if no response to CCCPR. Given we dont really know the answer could this recommendation be softened to something along the lines of ‘not initiating CPR with open chest’. ‘Do not attempt’ seems very definite
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