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MON-06-v1
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RECOVER 2.0 Worksheet
QUESTION ID: MON-06
PICO Question:
In dogs and cats at risk of CPA (e.g., under anesthesia, in shock, in respiratory distress, post-ROSC) (P), does ECG monitoring (I) compared to no ECG monitoring (C) improve ... (O)?
Outcomes:
Time to identification of CPA,Time to start CPR,Favorable neurologic outcome,Survival to Discharge,ROSC
Prioritized Outcomes (1= most critical; final number = least important):
1.Favorable neurologic outcome
2.Survival to Discharge
3.ROSC
4.Time to start CPR*
5.Time to identification of CPA*
Domain chairs: Selena Lane, Ben Brainard
Evidence evaluators: Lisa Powell, Alex Blutinger
Conflicts of interest:
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 1: Favorable neurologic outcome |
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1 |
OB |
0 |
- - |
- |
0 |
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Very low |
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Outcome 2: Survival discharge |
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6 |
OB |
0 |
- - |
- |
0 |
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Very low |
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Outcome 3: ROSC |
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4 |
OB |
0 |
- - |
- |
0 |
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Very low |
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Outcome 4: Time to start CPR |
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1 |
CT |
- |
- |
0 |
0 |
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Very low |
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1 |
OB |
- |
- |
0 |
0 |
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Very low |
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1 |
Exp |
0 |
-- |
- |
0 |
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Very low |
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Outcome 5: Time to identify CPA |
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14 |
OB |
- |
- |
0 |
0 |
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4 |
EXP |
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PICO Question Summary
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Introduction |
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Continuous ECG monitoring may be observed directly or remotely and can alert nurses and doctors to the presence of arrhythmias that may be associated with CPA. Because ECG devices and monitoring capability can be limited in some hospitals, this query was designed to determine if ECG monitoring in patients at risk of CPA affected the outcomes of interest.
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Consensus on science |
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Outcome 1: Favorable neurologic outcome
For the most critical outcome of favorable neurologic outcome, 1 retrospective, registry-based observational study in people was identified that addressed the PICO question (very low quality of evidence, downgraded for very serious indirectness and imprecision).1 In 6789 patients who developed CPA due to a shockable arrest rhythm, the adjusted odds ratio for FNO among patients defibrillated more than 2 minutes after developing CPA was 0.74 (95% CI = 0.56–0.96, P = 0.02). Additionally, the odds ratio for delayed defibrillation in patients managed in an inpatient unit with telemetry was 0.47 (95% CI = 0.41–0.53, P < 0.001). These data suggest that patients with continuous telemetry-based ECG monitoring were more likely to have prompt defibrillation and improved FNO.
Outcome 2: Survival to discharge
For the next most critical outcome of survival to discharge, 6 observational studies in people were identified that addressed the PICO question (very low quality of evidence, downgraded for very serious indirectness and serious imprecision).1–6 In human hospitals, hospitalization in an unmonitored ward is associated with lower frequency of survival to discharge after IHCA.1,2 One particular at-risk group that experienced IHCA secondary to aspiration pneumonia had a lower frequency of survival to discharge when CPA occurred in an unmonitored area.2 The primary factor leading to continuous monitoring in human patients was ongoing myocardial infarction, which may limit the applicability of these findings to dogs and cats.3 These studies did not directly compare ECG monitoring to no ECG monitoring however, and most patients with ECG monitoring were housed in wards with nurses with more expertise caring for higher acuity patients. Other studies in people support an increased chance of survival to hospital discharge following IHCA and resuscitation in patients housed in areas that are better monitored (including, but not limited to continuous ECG) compared to IHCA in locations where the level of monitoring was lower and continuous ECG-monitoring absent.3–5 Two observational studies found that continuous ECG monitoring by a central station did not improve survival to discharge following IHCA.6,7 The Mohammed (2015) study specifically evaluated the use of continuous telemetry monitoring in non-critically ill patients.6 The variability of quality of CPR is not directly addressed in these studies, although the location of many monitored patients in higher acuity wards likely results in some bias regarding familiarity of the attending nurses and physicians with CPR protocol.
Outcome 3: ROSC
Four observational studies in people were identified that informed the answer to this PICO question for this outcome (very low quality of evidence, downgraded for very serious indirectness and serious imprecision).1,2,6,7 Two observational studies in people specifically evaluated ECG monitoring and ROSC for IHCA, finding that continuous ECG monitoring was associated with an increased frequency of ROSC.1,7 In addition, one observational study in people evaluating patients with aspiration pneumonia compared to patients with respiratory failure due to other causes found that the latter group was more frequently monitored with continuous ECG and had a higher frequency of ROSC than patients with aspiration pneumonia.2 Only one observational study in non-critically ill patients found no effect of continuous monitoring with telemetry on ROSC.6
Outcomes 4 and 5: Time to start CPR, Time to identify CPA
Because substantial evidence was available to inform an answer to this PICO question for the 3 most critical outcomes, only a cursory evaluation of the literature for the 2 least critical outcomes was done. Many of the studies cited above also demonstrated decreased time to diagnosing CPA and initiating BLS and ALS interventions in patients with continuous ECG monitoring.1,2,4 In pediatric populations, however, ECG monitoring may not reliably identify all CPA events. In one study, children with an arrest rhythm of PEA experienced a significant delay from onset of CPA to start of CPR compared to infants with ECG diagnoses of either bradycardia or ventricular fibrillation.8,9 In experimental studies in dogs subjected to uncoupling of electrical and mechanical heart function and pigs subjected to asphyxial arrest, the ECG indicated either no change or bradyarrhythmias for a period of time (4-6 minutes) without a perfusing rhythm, highlighting the major problem with sole reliance on ECG monitoring to diagnose CPA in certain scenarios.10,11 In a study of pediatric CPA, other monitored parameters such as blood pressure and pulse oximetry more accurately diagnosed CPA than the ECG.8 However, another study showed that diagnosis of bradycardia in pre-term infants was slower with a pulse oximeter than an ECG.12
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Treatment recommendation |
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We recommend continuous ECG monitoring in dogs and cats at risk of CPA (e.g., under anesthesia, in shock, in respiratory distress, post-ROSC, aspiration risk). (strong recommendation, very low quality of evidence)
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Justification of treatment recommendation |
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Although much of it is indirect, there is substantial evidence of better outcomes in patients with IHCA that have continuous ECG monitoring in place at the time of the arrest. However, ECG monitoring alone is not adequate to diagnose CPA in patients with PEA or pulseless VT, and other monitoring (such as arterial blood pressure, pulse oximetry, and end tidal CO2 monitoring) may provide important additional information to increase the sensitivity of the monitoring plan for CPA.
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Knowledge gaps |
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There are no veterinary studies in hospitalized dogs and cats investigating the utility of ECG monitoring for the diagnosis of CPA in at-risk populations. In addition, there are limited data available to inform the decision of which patients would benefit most from continuous ECG monitoring. |
References:
1. Chan PS, Krumholz HM, Nichol G, Nallamothu BK. Delayed time to defibrillation after in-hospital cardiac arrest. N Engl J Med. 2008;358(1):9-17.
2. Albert M, Herlitz J, Rawshani A, et al. Cardiac arrest after pulmonary aspiration in hospitalised patients: a national observational study. BMJ Open. 2020;10(3):e032264.
3. Thorén A, Rawshani A, Herlitz J, et al. ECG-monitoring of in-hospital cardiac arrest and factors associated with survival. Resuscitation. 2020;150:130-138.
4. Hessulf F, Karlsson T, Lundgren P, et al. Factors of importance to 30-day survival after in-hospital cardiac arrest in Sweden - A population-based register study of more than 18,000 cases. Int J Cardiol. 2018;255:237-242.
5. Cleverley K, Mousavi N, Stronger L, et al. The impact of telemetry on survival of in-hospital cardiac arrests in non-critical care patients. Resuscitation. 2013;84(7):878-882.
6. Mohammad R, Shah S, Donath E, et al. Non-critical care telemetry and in-hospital cardiac arrest outcomes. J Electrocardiol. 2015;48(3):426-429.
7. Yen KC, Chan YH, Wu CT, et al. Resuscitation outcomes of a wireless ECG telemonitoring system for cardiovascular ward patients experiencing in-hospital cardiac arrest. J Formos Med Assoc. Published online 2020.
8. Olson M, Helfenbein E, Su L, et al. Variability in the time to initiation of CPR in continuously monitored pediatric ICUs. Resuscitation. 2018;127:95-99.
9. Hörner E, Schebesta K, Hüpfl M, Kimberger O, Rössler B. The Impact of Monitoring on the Initiation of Cardiopulmonary Resuscitation in Children: Friend or Foe? Anesth Analg. 2016;122(2):490-496.
10. Mazzia VDB, Ellis CH, Siegel H, Hershey SG. The Electrocardiograph as a Monitor of Cardiac Function in the Operating Room. JAMA: The Journal of the American Medical Association. 1966;198(2):103-107.
11. Solevag AL, Luong D, Lee TF, O’Reilly M, Cheung PY, Schmolzer GM. Non-perfusing cardiac rhythms in asphyxiated newborn piglets. PLoS One. 2019;14(4):e0214506.
12. Iglesias B, Rodri Guez MAJ, Aleo E, Criado E, Marti Nez-Orgado J, Arruza L. 3-lead electrocardiogram is more reliable than pulse oximetry to detect bradycardia during stabilisation at birth of very preterm infants. Arch Dis Child Fetal Neonatal Ed. 2018;103(3):F233-F237.
Supplemental:
Important, but not in the reviewed papers list:
Hessulf F, Karlsson T, Lundgren P, Aune S, Strömsöe A, Södersved Källestedt ML, Djärv T, Herlitz J, Engdahl J. Factors of importance to 30-day survival after in-hospital cardiac arrest in Sweden - A population-based register study of more than 18,000 cases. Int J Cardiol. 2018 Mar 15;255:237-242.
Cleverley K, Mousavi N, Stronger L, Ann-Bordun K, Hall L, Tam JW, Tischenko A, Jassal DS, Philipp RK. The impact of telemetry on survival of in-hospital cardiac arrests in non-critical care patients. Resuscitation. 2013 Jul;84(7):878-82.
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