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MON-10-v1
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1 RECOVER 2.0 Worksheet
2 QUESTION ID: MON-10
3
PICO Question: In cats and dogs with CPA (P), does achieving any other specific ETCO2 during CPR (I), compared to achieving ETCO2 ≥ 15 mm Hg (C), improve ... (O)?
4 Outcomes: Favorable neurologic outcome, Survival to discharge, ROSC
5 Prioritized Outcomes (1= most critical; final number = least important):
6 1.Favorable neurologic outcome
7 2.Survival to Discharge
8 3.ROSC
9
Domain chairs: Selena Lane, Ben Brainard; final edit by Jamie Burkitt
10 Evidence evaluators: Aubrey Hnatusko, Tiffany Jagodich
11 Conflicts of interest: None reported
12 Search strategy: See attached document
13 Evidence Review:
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14 Study Design |
15 Reduced Quality Factors
16 0 = no serious, - = serious,
17 - - = very serious |
18 Positive Quality Factors
19 0 = none, + = one, ++ = multiple |
20 Dichotomous Outcome Summary |
21 Non-Dichotomous Outcome Summary
22 Brief description |
23 Overall Quality
24
High, moderate, low, |
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25 No of studies |
26 Study Type |
27 RoB |
28 Indirectness |
29 Imprecision |
30 Inconsistency |
31 Large Effect |
32 Dose-Response |
33 Confounder |
34 # Intervention with Outcome |
35 # Control with Outcome |
36 RR (95% CI) |
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37 Outcome: Favorable neurologic outcome |
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38 3 |
39 OB |
40 0 |
41 - - |
42 0 |
43 - |
44 0 |
45 0 |
46 0 |
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47 Very low |
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48 Outcome: Survival to discharge |
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49 3 |
50 OB |
51 0 |
52 - - |
53 0 |
54 0 |
55 0 |
56 0 |
57 0 |
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58 Very low |
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59 Outcome: ROSC |
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60 12 |
61 OB |
62 0 |
63 - - |
64 0 |
65 0 |
66 0 |
67 0 |
68 0 |
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69 Very low |
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70 1 |
71 EX |
72 0 |
73 - |
74 - |
75 0 |
76 0 |
77 0 |
78 0 |
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79 Very low |
80 PICO Question Summary
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81 Introduction |
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82 While it has been established that higher ETCO2 values are associated with better outcomes in CPR in people, the minimum ETCO2 target in dogs and cats is unknown.1 Hofmeister et al. (2009) reported that in their population of dogs, 17 of 18 (94%) with an ETCO2 < 15 mm Hg during CPR were not successfully resuscitated, whereas 25 of 29 (86%) with a ETCO2 ≥ 15 mm Hg achieved ROSC.2ofJ In the same study, 5 of 9 cats with a ETCO2 < 20 mm Hg were not successfully resuscitated, whereas 9 of 10 cats with a ETCO2 ≥ 20 mm Hg achieved ROSC. The best way to use ETCO2 to improve chest compression technique in dogs and cats is unknown.
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83 Consensus on science |
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84 Outcome 1: Favorable neurologic outcome
85 For the most critical outcome of FNO, 3 observational studies in people (very low quality of evidence, downgraded for very serious indirectness and inconsistency) were identified that addressed the PICO question. In 803 adults with IHCA, Sutton (2016) found that ETCO2 > 10 mmHg during CPR was significantly associated with FNO compared to people with ETCO2 ≤ 10 mmHg (OR 2.31, CI95 1.31, 4.09; P = 0.004).3 Calbay (2019) found no association between continuous ETCO2 value during CPR and FNO in 155 adults with OHCA.4 Finally, in 43 pediatric patients with IHCA, Berg et al (2018) found that all children who survived to discharge did so with a FNO, and that both survivors and non-survivors achieved median ETCO2 values > 20 mm Hg during CPR.5
86 Outcome 2: Survival to discharge
87 For the next most critical outcome of survival to discharge, we identified 3 observational studies in people (very low quality of evidence, downgraded for very serious indirectness) that address the PICO question. In 803 adults with IHCA, Sutton (2016) found that ETCO2 > 10 mmHg during CPR was associated with survival to hospital discharge compared to patients with ETCO2 ≤ 10 mmHg (OR 2.41, CI95 1.35, 4.30; P = 0.003).3 A prospective, observational study in 102 adults undergoing CPR in the emergency department found that median ETCO2 during CPR was higher (35 mmHg) in patients that survived to hospital admission than in nonsurvivors (13.7 mmHg, P < 0.01); ETCO2 > 16 mmHg predicted survival to hospital admission.6 In 43 pediatric patients with IHCA, Berg et al. (2018) found no difference in survival to discharge when comparing pediatric patients with mean ETCO2 > 20 mmHg to those with lower mean ETCO2 during CPR.5
88 Outcome 3: ROSC
89 For the next critical outcome of ROSC, 12 observational studies (very low quality of evidence, downgraded for very serious indirectness)5,7–17 and 1 experimental study in dogs (very low quality of evidence, downgraded for serious indirectness and imprecision)18 were identified that address the PICO question.
90 Observational clinical veterinary studies:
91 In a registry study of 109 dogs and cats undergoing CPR, median ETCO2 was significantly higher (23 mmHg) in those that achieved ROSC than in those that did not (15 mmHg; P = 0.0004); ETCO2 of 16.5 mmHg was recommended as the cutoff to maximize likelihood of ROSC (sensitivity 75%, CI95 60%, 86%; specificity 64%, CI95 52%,75%).7 One clinical observational study in 35 dogs and cats undergoing CPR found that patients that achieved ROSC had significantly higher initial (P = 0.0083), peak (P < 0.0001), mean (P < 0.0001), and change in (P = 0.0004) ETCO2 than patients that did not achieve ROSC; optimal ETCO2 cutoff to predict ROSC was 18 mmHg.8
92 Observational clinical human studies of 100 people or more:
93 A prospective, observational study in 737 adults with OHCA found that ETCO2 at 20 minutes into ALS was higher in patients that achieved ROSC (32.8 mmHg ± 9.1 mmHg) than in those that did not (6.9 ± 2.2 mmHg; P < 0.001).11 One observational study in 575 adults with OHCA found that mean ETCO2 was higher in patients with ROSC than in those that did not achieve ROSC, regardless of cause of arrest or arrest rhythm.17 One prospective observational study of 114 adults with OHCA found significantly higher ETCO2 from 5 minutes into CPR to the final value obtained in people achieving ROSC than in those who did not, regardless of cause of arrest.16 Finally, Singer (2018) described an optimal ETCO2 target of ≥ 19 mm Hg based on the prospective observational study of 100 adult human patients with OHCA.13
94 Observational clinical human studies of 99 people or fewer:
95 An observational study in 97 adults with IHCA or OHCA found that the final ETCO2 (36.4±4.46 mm Hg vs 11.74±7.01 mm Hg; P < 0.05) and the difference between initial and final ETCO2 (P < 0.05) were different between patients that achieved ROSC and those that did not.12 An observational study of OHCA in 90 adults found that people who achieved ROSC had significantly higher ETCO2 just prior to ROSC (31 ± 5.3 mmHg) than those who did not achieve ROSC by 20 minutes into ALS (3.9 ± 2.8 mmHg).14 Savastano (2017) evaluated defibrillation success of 207 defibrillation events in 62 people with OHCA in shockable rhythms and determined that a higher ETCO2 was associated with defibrillation success (P = 0.003; P for trend < 0.001); no shocks administered to patients with ETCO2 > 45 mm Hg were unsuccessful.10 Finally, a study in 32 young to middle-aged adults suffering non-traumatic OHCA or IHCA found that mean ETCO2 during CPR was lower in those who failed to achieve ROSC (19.1 ± 7.8 mm Hg) than in those that achieved ROSC (26.3 ± 6.5 mm Hg; P = 0.01).9
96 Only 2 identified studies found a lack of association between ETCO2 and ROSC, including one in a small population of adults15 and one in pediatrics.5
97 Experimental study in target species:
98 Finally, an experimental study in dogs supported the relationship of higher ETCO2 with ROSC, however showed much lower mean ETCO2 in the survivor group than reported in other studies (9.6 +/- 3.2 mm Hg).18 |
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99 Treatment recommendation |
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100 We recommend optimizing CPR to maximize ETCO2 to no less than 18 mmHg in dogs and cats undergoing CPR. (strong recommendation, very low quality of evidence)
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101 Justification of treatment recommendation |
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102 Observational veterinary and human studies, in addition to some experimental data, suggest that higher ETCO2 targets are positively correlated with ROSC. There was no direct comparison identified of 15 mm Hg versus higher ETCO2 values, which was the specific PICO question. Therefore, this recommendation is to target the high value found in clinical observational studies of dogs and cats (ETCO2 > 18 mm Hg), with the understanding that as a concept, higher ETCO2s into the low 30s in mm Hg are associated with ROSC in observational studies of people. |
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103 Knowledge gaps |
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104 Optimal ETCO2 targets in dogs and cats undergoing CPR are unknown, and larger studies are warranted. The effects of precise targets, and the collateral damage (ie. more damage to thoracic structures) that may occur with more aggressive CPR to achieve higher ETCO2 raises questions about how high an ETCO2 is too high, or if such a value exists. |
105 References:
106 1. Levine RL, Wayne MA, Miller CC. End-tidal carbon dioxide and outcome of out-of-hospital cardiac arrest. N Engl J Med. 1997;337(5):301-306.
107 2. Hofmeister EH, Brainard BM, Egger CM, Kang SW. Prognostic indicators for dogs and cats with cardiopulmonary arrest treated by cardiopulmonary cerebral resuscitation at a university teaching hospital. Journal of the American Veterinary Medical Association. 2009;235(1):50-57.
108 3. Sutton RM, French B, Meaney PA, et al. Physiologic monitoring of CPR quality during adult cardiac arrest: A propensity-matched cohort study. Resuscitation. 2016;106:76-82.
109 4. Çalbay A, Çakır Z, Bayramoğlu A. Prognostic value of blood gas parameters and end-tidal carbon dioxide values in out-of-hospital cardiopulmonary arrest patients. Turk J Med Sci. 2019;49(5):1298-1302.
110 5. Berg RA, Reeder RW, Meert KL, et al. End-tidal carbon dioxide during pediatric in-hospital cardiopulmonary resuscitation. Resuscitation. 2018;133:173-179.
111 6. Salen P, O’Connor R, Sierzenski P, et al. Can cardiac sonography and capnography be used independently and in combination to predict resuscitation outcomes? Acad Emerg Med. 2001;8(6):610-615.
112 7. Hoehne SN, Hopper K, Epstein SE. Prospective Evaluation of Cardiopulmonary Resuscitation Performed in Dogs and Cats According to the RECOVER Guidelines. Part 2: Patient Outcomes and CPR Practice Since Guideline Implementation. Frontiers in Veterinary Science. 2019;6.
113 8. Hogen T, Cole SG, Drobatz KJ. Evaluation of end-tidal carbon dioxide as a predictor of return of spontaneous circulation in dogs and cats undergoing cardiopulmonary resuscitation. J Vet Emerg Crit Care (San Antonio). 2018;28(5):398-407.
114 9. Yilmaz G, Silcan M, Serin S, Caglar B, Erarslan Ö, Parlak İ. A comparison of carotid doppler ultrasonography and capnography in evaluating the efficacy of CPR. Am J Emerg Med. 2018;36(9):1545-1549.
115 10. Savastano S, Baldi E, Raimondi M, et al. End-tidal carbon dioxide and defibrillation success in out-of-hospital cardiac arrest. Resuscitation. 2017;121:71-75.
116 11. Kolar M, Krizmaric M, Klemen P, Grmec S. Partial pressure of end-tidal carbon dioxide successful predicts cardiopulmonary resuscitation in the field: a prospective observational study. Crit Care. 2008;12(5):R115.
117 12. Ozturk F, Parlak I, Yolcu S, et al. Effect of End-Tidal Carbon Dioxide Measurement on Resuscitation Efficiency and Termination of Resuscitation. Turk J Emerg Med. 2014;14(1):25-31.
118 13. Singer AJ, Nguyen RT, Ravishankar ST, et al. Cerebral oximetry versus end tidal CO(2) in predicting ROSC after cardiac arrest. Am J Emerg Med. 2018;36(3):403-407.
119 14. Wayne MA, Levine RL, Miller CC. Use of end-tidal carbon dioxide to predict outcome in prehospital cardiac arrest. Ann Emerg Med. 1995;25(6):762-767.
120 15. Garnett AR, Ornato JP, Gonzalez ER, Johnson EB. End-tidal carbon dioxide monitoring during cardiopulmonary resuscitation. JAMA. 1987;257(4):512-515.
121 16. Lah K, Križmarić M, Grmec S. The dynamic pattern of end-tidal carbon dioxide during cardiopulmonary resuscitation: difference between asphyxial cardiac arrest and ventricular fibrillation/pulseless ventricular tachycardia cardiac arrest. Crit Care. 2011;15(1):R13.
122 17. Heradstveit BE, Sunde K, Sunde GA, Wentzel-Larsen T, Heltne JK. Factors complicating interpretation of capnography during advanced life support in cardiac arrest--a clinical retrospective study in 575 patients. Resuscitation. 2012;83(7):813-818.
123 18. Sanders AB, Ewy GA, Bragg S, Atlas M, Kern KB. Expired PCO2 as a prognostic indicator of successful resuscitation from cardiac arrest. Ann Emerg Med. 1985;14(10):948-952.
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