The implementation of RECOVER guidelines into CPR protocols is showing promise as a way to improve outcomes for veterinary patients.

It’s every veterinary professional’s worst fear. A healthy animal goes into a routine and supposedly low-risk procedure… and arrests. What happens in the next seconds to minutes will likely determine the patient’s outcome. How will the team respond? With a purposeful, coordinated transition to high quality, evidence-based CPR? With discombobulated flailing and yelling? Something in between? How does a team move from fumbling attempts at resuscitation to purposeful, coordinated CPR? What is the best way to perform CPR, and who should lead the resuscitation efforts? And how can veterinary professionals access high quality, hands-on training? These are the questions being addressed and answered by the Reassessment Campaign on Veterinary Resuscitation (RECOVER) Initiative.

WHAT IS RECOVER AND WHAT ARE THE GUIDELINES?

The RECOVER initiative was created in 2010 by veterinary emergency and critical care specialists with the purpose of organizing and disseminating the first true evidence-based veterinary cardiopulmonary resuscitation (CPR) guidelines. It is a collaborative effort by members of the American College of Veterinary Emergency and Critical Care (ACVECC) and the Veterinary Emergency and Critical Care Society (VECCS). The RECOVER Initiative has three goals:

1. Develop and update evidence-based, consensus veterinary CPR guidelines through extensive review of primary CPR literature.
2. Provide standardized CPR training to veterinary professionals and pet owners, offering CPR certification through the ACVECC and endorsed by the VECCS.
3. Inform and support scientific research to improve the approach to CPR in animals.¹

The RECOVER guidelines^2-8 were published in 2012, and are the first published consensus recommendations for CPR in veterinary medicine. It was a massive undertaking that involved over 100 veterinary professionals from ACVECC and VECCS, working with advice from the International Liaison Committee on Resuscitation (ILCOR), the group responsible for performing the extensive literature surveys upon which evidence-based human CPR guidelines are developed.¹ The guidelines are freely available online in a special issue of the Journal of Veterinary Emergency and Critical Care, Volume 22, Issue s1 at https://onlinelibrary.wiley.com/toc/14764431/22/s1.^2-8 They include when and how to initiate CPR; how to perform chest compressions; drug dose and timing recommendations; and monitoring devices and techniques that have a beneficial role during the resuscitation process and those that do not. The guidelines also include visual aids to guide caregivers through the steps of CPR, drug administration, post-resuscitation care, and team dynamics.

Once the guidelines were written, a consistent, standardized training program could be developed. In human medicine, establishing ILCOR and developing evidence-based clinical guidelines allowed consistent training for human healthcare professionals and the lay public, which has led directly to improved patient outcomes.^9,10 Shortly after completion of its guidelines, RECOVER established a standardized training and certification program on this model for veterinary professionals, and recently released a course for the lay public.

Studies evaluating veterinary professionals’ knowledge of the CPR guidelines and outcomes before and after they were published are sparse; but those that have been published suggest that knowledge of these guidelines is spreading through the veterinary professional community, and outcomes may be improving.^11-14 Research into many areas of resuscitation is ongoing in many hospitals and institutions, and includes a large, multinational CPR database maintained by the RECOVER Initiative, similar to human databases, where registered hospitals enter data from every CPR event performed within them.

IT’S NOT FUTILE — CPR OUTCOMES

Owners and veterinary professionals alike often ask questions such as “is it worth it”, “how well does it work”, or “can you really get them back?” It is worth it, it can work, and you can get some of them back. As in human medicine, the number of survivors is low, but that doesn’t make it futile. We know the outcomes between people and animals differ, and making direct comparisons is difficult for several reasons. There are decades’ worth of data and thousands of publications evaluating human outcomes, but very limited data in veterinary medicine to date. Most of the available veterinary data comes from university and specialty referral hospitals caring for the sickest of patients that often have a poor prognosis due to their underlying disease. In addition, the epidemiology of underlying pathology leading to arrest is different between humans and animals. Acknowledging these limitations, some comparisons are still worth discussing. Overall, approximately 45% of humans and 35% to 55% of dogs and cats will achieve return of spontaneous circulation (ROSC).^11,12,15,16 Many of these patients will subsequently die in the hospital or (in veterinary medicine) be euthanized due to perceived poor prognosis or lack of financial ability to pursue treatment.¹⁶ In humans, there is a significant difference between patients that arrest outside the hospital (OHCA) versus in the hospital (IHCA). Survival to discharge for humans that arrest in the hospital is 17% to 34%, while OHCA sees only about 10% survival.¹⁵ Survival to discharge in dogs and cats is 6% to 19%,^11,12,16 with less variation between in-hospital and out-of-hospital arrests, but also with significantly less data from which to make this determination.¹⁵

Of particular note, dogs and cats that arrest due to anesthesia- or sedation-related complications are much more likely to survive. A study by Hofmeister et al conducted prior to publication of the RECOVER guidelines found that 47% of dogs and 42% of cats that arrested in association with an anesthetic event (time from induction to extubation) survived to discharge.¹¹ Hoehne et al found similar results, noting that cats and dogs that arrested in association with anesthesia or sedation were 14.8 times more likely to survive and be discharged than those with other causes of arrest.¹⁶ This statistic, and the finding in both humans and animals that a shorter period of time from arrest to initiation of CPR is a significant factor in survival,^15,16 suggests it is imperative for veterinary professionals of all levels of qualification to be prepared to perform high quality CPR in any setting —particularly those who work with sedated or anesthetized animals.

Data in human medicine shows that development of evidence-based standardized training programs does have a positive impact on performance and patient outcomes.¹⁰ A single veterinary publication that evaluates performance in a hospital before and after implementation of the RECOVER guidelines shows significant outcome improvements in this hospital’s performance.¹⁷ This study evaluated outcome in 141 dogs — 68 resuscitated prior to implementing RECOVER guidelines and 73 after implementing RECOVER guideline-based CPR. The study reports no difference between the groups with regards to baseline patient characteristics. These results are impressive: prior to performing guideline-based resuscitation, the group had 17% ROSC with 0% survival to discharge. Following implementation of RECOVER guideline-based CPR, they achieved 43% ROSC and 5% survival to discharge. This study is also notable because it is one of the few veterinary CPR studies not performed in a tertiary veterinary hospital, indicating that positive outcomes can be achieved in the non-tertiary, non-24-hour environment.

¹RECOVER website

²Boller M, Fletcher DJ. RECOVER evidence and knowledge gap analysis on veterinary CPR. Part 1: Evidence analysis and consensus process: collaborative path toward small animal CPR guidelines. J Vet Emerg Crit Care (San Antonio). 2012;22 Suppl 1:S4-S12. doi:10.1111/j.1476-4431.2012.00758.x

³McMichael M, Herring J, Fletcher DJ, Boller M; RECOVER Preparedness and Prevention Domain Worksheet Authors. RECOVER evidence and knowledge gap analysis on veterinary CPR. Part 2: Preparedness and prevention [published correction appears in J Vet Emerg Crit Care (San Antonio). 2013 Sep-Oct;23(5):571]. J Vet Emerg Crit Care (San Antonio). 2012;22 Suppl 1:S13-S25. doi:10.1111/j.1476-4431.2012.00752.x

⁴Hopper K, Epstein SE, Fletcher DJ, Boller M; RECOVER Basic Life Support Domain Worksheet Authors. RECOVER evidence and knowledge gap analysis on veterinary CPR. Part 3: Basic life support. J Vet Emerg Crit Care (San Antonio). 2012;22 Suppl 1:S26-S43. doi:10.1111/j.1476-4431.2012.00753.x

⁵Rozanski EA, Rush JE, Buckley GJ, Fletcher DJ, Boller M; RECOVER Advanced Life Support Domain Worksheet Authors. RECOVER evidence and knowledge gap analysis on veterinary CPR. Part 4: Advanced life support. J Vet Emerg Crit Care (San Antonio). 2012;22 Suppl 1:S44-S64. doi:10.1111/j.1476-4431.2012.00755.x

⁶Brainard BM, Boller M, Fletcher DJ; RECOVER Monitoring Domain Worksheet Authors. RECOVER evidence and knowledge gap analysis on veterinary CPR. Part 5: Monitoring. J Vet Emerg Crit Care (San Antonio). 2012;22 Suppl 1:S65-S84. doi:10.1111/j.1476-4431.2012.00751.x

⁷Smarick SD, Haskins SC, Boller M, Fletcher DJ; RECOVER Post-Cardiac Arrest Care Domain Worksheet Authors. RECOVER evidence and knowledge gap analysis on veterinary CPR. Part 6: Post-cardiac arrest care. J Vet Emerg Crit Care (San Antonio). 2012;22 Suppl 1:S85-S101. doi:10.1111/j.1476-4431.2012.00754.x

⁸Fletcher DJ, Boller M, Brainard BM, et al. RECOVER evidence and knowledge gap analysis on veterinary CPR. Part 7: Clinical guidelines. J Vet Emerg Crit Care (San Antonio). 2012;22 Suppl 1:S102-S131. doi:10.1111/j.1476-4431.2012.00757.x

⁹Holmberg M, Holmberg S, Herlitz J. Effect of bystander cardiopulmonary resuscitation in out-of-hospital cardiac arrest patients in Sweden. Resuscitation. 2000;47(1):59-70. doi:10.1016/s0300-9572(00)00199-4

¹⁰Sodhi K, Singla MK, Shrivastava A. Impact of advanced cardiac life support training program on the outcome of cardiopulmonary resuscitation in a tertiary care hospital. Indian J Crit Care Med. 2011;15(4):209-212. doi:10.4103/0972-5229.92070

¹¹Hofmeister EH, Brainard BM, Egger CM, Kang S. Prognostic indicators for dogs and cats with cardiopulmonary arrest treated by cardiopulmonary cerebral resuscitation at a university teaching hospital. J Am Vet Med Assoc. 2009;235(1):50-57. doi:10.2460/javma.235.1.50

¹²Hoehne 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. Front Vet Sci. 2019;6:439. Published 2019 Dec 10. doi:10.3389/fvets.2019.00439

¹³Boller M, Kellett-Gregory L, Shofer FS, Rishniw M. The clinical practice of CPCR in small animals: an internet-based survey. J Vet Emerg Crit Care (San Antonio). 2010;20(6):558-570. doi:10.1111/j.1476-4431.2010.00571.x

¹⁴Gillespie Í, Fletcher DJ, Stevenson MA, Boller M. The Compliance of Current Small Animal CPR Practice With RECOVER Guidelines: An Internet-Based Survey. Front Vet Sci. 2019;6:181. Published 2019 Jun 11. doi:10.3389/fvets.2019.00181

¹⁵Peberdy MA, Kaye W, Ornato JP, et al. Cardiopulmonary resuscitation of adults in the hospital: a report of 14720 cardiac arrests from the National Registry of Cardiopulmonary Resuscitation. Resuscitation. 2003;58(3):297-308. doi:10.1016/s0300-9572(03)00215-6

¹⁶Hoehne SN, Epstein SE, Hopper K. Prospective Evaluation of Cardiopulmonary Resuscitation Performed in Dogs and Cats According to the RECOVER Guidelines. Part 1: Prognostic Factors According to Utstein-Style Reporting. Front Vet Sci. 2019;6:384. Published 2019 Nov 7. doi:10.3389/fvets.2019.00384

¹⁷Kawase K, Ujiie H, Takaki M, Yamashita K. Clinical outcome of canine cardiopulmonary resuscitation following the RECOVER clinical guidelines at a Japanese nighttime animal hospital. J Vet Med Sci. 2018;80(3):518-525. doi:10.1292/jvms.17-0107