RECOVER CPR Initiative Overview for Veterinary Professionals

• This article outlines the Reassessment Campaign on Veterinary Resuscitation (RECOVER) initiative.
• The article reviews the established evidence-based guidelines for veterinary CPR, which are internationally recognised and endorsed by the American College of Veterinary Emergency and Critical Care (ACVECC) and Veterinary Emergency and Critical Care Society (VECCS).

RECOVER Certifications and Process

• After reading this article, participants should be able to prepare for and recognise cardiopulmonary arrest (CPA)
• Participants should be able to initiate basic life support, provide advanced life support, monitor the CPA patient and provide post-CPA care.
• Participants will also have access on the different RECOVER certifications available and certification process.

RECOVER Goal

• The goal was to evaluate evidence-based medicine and form consensus guidelines for CPR in canine and feline patients.
• The result was refined recommendations that the veterinary community could adopt and follow.
• The RECOVER guidelines are considered open access (www.veccs.org/recover-cpr)

RECOVER Initiative

• The initiative aimed to address five critical aspects surrounding cardiopulmonary arrest (CPA) for the veterinary team: preparedness and prevention, basic life support (BLS), advanced life support (ALS), monitoring, and post-cardiopulmonary arrest care.

Preparedness and Prevention

• Preparation includes having both the veterinary team and hospital be trained to provide cardiopulmonary resuscitation (CPR) in an organised and efficient manner.
• Being prepared first means providing CPR training for all staff members.
• Including an instructive component as well as hands-on practise is important.
• Instructive training improves cognitive skills and teaches staff how CPR is correctly performed.
• Hands-on training allows for the development of psychomotor skills so that chest compressions and ventilation are provided effectively.
• Regular refresher training for both instructive and hands-on is recommended at least every six months to prevent loss of knowledge and psychomotor skills.
• Each hospital should have a designated emergency area with a centrally located, fully stocked crash cart.
• Crash cart considerations: The crash cart should be organised, routinely audited (ideally daily) to ensure no supplies are missing, standardised location and content.
• Having a multi-parameter monitor in the vicinity of the crash cart and cognitive aids readily accessible is beneficial.
• Cognitive aids should have clear visibility and training on the use of them, as they have been shown to improve compliance of RECOVER guidelines.
• RECOVER created three essential cognitive aids: CPR Algorithm, CPR Emergency Drugs and Doses, and Post-Cardiac Arrest Care Algorithm.
• Having an advanced directive status for each patient in the hospital is a final consideration in preparedness.
• Knowing the owner's wishes for their pet ahead of time eliminates confusion and delay in providing CPR efforts.

Basic Life Support

• Basic life support (BLS) encompasses recognition of cardiopulmonary arrest (CPA), initiation of chest compressions, establishing an airway, and delivering breaths to provide ventilation.
• Prompt recognition and immediate response to CPA are essential to improve outcome and chances of patient survival.
• Signs of impending arrest are summarised in Table 2.
• Rapid assessment of the patient (less than 10-15 seconds) should be done to determine if the animal is responsive and if they're breathing.
• If the answer is no, a call for help should be shouted and BLS should be initiated.
• Evaluation of the patient's circulation status (i.e. heartbeat, pulse) is not performed during this rapid assessment.
• Taking heartbeat or pulse is time taken away from initiating life-saving chest compressions therefore is discouraged.
• There is considerable inaccuracy in a rescuer's ability to correctly determine if a pulse is present or absent.
• It is more detrimental to delay starting chest compressions on a CPA patient than performing chest compressions in an animal that is not in CPA.
• The ABCs (airway, breathing, circulation) was updated to CAB (circulation, airway, breathing).
• Chest compressions are necessary for blood flow and to improve the chances of return of spontaneous circulation (ROSC).
• The process of intubating and providing breaths is longer, when providing chest compressions can start immediately.
• By focusing on compressions first, there is less delay in starting CPR efforts.
• Chest compressions have two main goals, to restore cardiac/pulmonary tissue circulation and deliver ventilation to oxygenate tissues and restore organ function.

Chest Compression Theories

• Cardiac pump theory: Blood flow is generated from direct compression of the heart through the thoracic wall, which simulates the systolic phase of a normal heartbeat.
• Location of the chest compression in the cardiac pump theory: Directly over the heart.
• Ideal candidates for the cardiac pump theory: Narrow- or keel-chested dogs, small dogs, cats and paediatric dogs and cats.
• Thoracic pump theory: Blood flow is generated from increased intrathoracic pressures during compressions, which drive blood through the heart chambers. Location of the chest compression in the thoracic pump theory: Over the widest aspect of the chest.
• Ideal candidates for the thoracic pump theory: Flat-chested dogs.
• Round-chested dogs are unique in that the compression point is directly over their sternum when in dorsal recumbency.
• Chest compressions should be delivered in lateral recumbency at a rate of 100-120 compressions/minute (cpm).

Chest Compression Technique

• Compression depth should be delivered by compressing one-third to one-half of the width of the patient's chest.
• Allow for full chest wall recoil between compression depths in order to optimise cardiac output.
• Rescuers should perform compressions by standing behind the patient.
• Having elbows locked and bending at the waist in order to draw compression power and force from their core rather than their arms is important.
• Even high-quality compressions only produce approximately 25-30% of normal cardiac output.

Intubation

• Intubation should occur as soon as possible once chest compressions start, with ventilation being delivered simultaneously.
• Ideally, intubation should be done in lateral recumbency so chest compressions aren't interrupted. -Using a laryngoscope ensures endotracheal versus oesophageal intubation.
• The breath delivery rate in dogs and cats should be 10 breaths per minute (bpm).
• Manual ventilation can be provided with either an AMBU bag connected to an oxygen source or a rebreathing bag connected to an anaesthetic circuit.
• The practice of performing compressions at 100-120 cpm and delivering breaths at 10 bpm should be done in uninterrupted 2-minute BLS cycles.
• It takes approximately 60 seconds of continuous chest compressions to build up cerebral perfusion pressure (CPP).
• At the end of each 2-minute BLS cycle, rescuers should rotate out to prevent fatigue and the patient should be rapidly assessed for ROSC before starting the next 2-minute cycle.

Advanced Life Support

• Advanced life support (ALS) encompasses aspects of CPR performed after initiation of BLS and until ROSC or cessation of CPR efforts occurs.
• Advanced life support (ALS) includes venous access, emergency drug administration, monitoring equipment and defibrillation if warranted
• Venous access is the preferred route to administer emergency drugs.
• In the event venous access cannot be achieved, alternative routes of drug administration include intraosseous (IO) or intratracheal (IT).
• Anything that can be given IV can be given IO at the same dosage.
• Drugs that are safe to give via the IT route: noradrenaline, atropine, vasopressin, lidocaine and adrenaline.
• The primary drug therapies used in CPR include vasopressors, parasympatholytics and anti-arrythmics.
• Additional drug therapies include reversal agents, alkalinising therapy and IV fluids.
• Use of vasopressors are essential as they improve cerebral and coronary perfusion.

Vasopressors

• Adrenaline is a catecholamine that improves arterial blood flow, cardiac contractility and heart rate by alpha and beta adrenergic activity.
• Vasopressin improves myocardial and cerebral oxygenation and maintains effectiveness despite hypoxemia and acidotic states.
• Parasympatholytics reduce the activity of the parasympathetic nervous system.
• Anti-arrhythmic agents such as lidocaine and amiodarone should be used to treat ventricular fibrillation or pulseless ventricular tachycardia in the event defibrillation is not available or if the arrhythmia is refractory to defibrillation.
• Reversal agents (naloxone, flumazenil, atipamezole) should be administered if there has been recent administration of a reversible drug.
• Sodium bicarbonate should only be considered after CPR efforts have lasted greater than 10 minutes
• Routine use of fluids in euvolemic patients is not recommended; it has been associated with decreased coronary perfusion from increased central venous pressure.
• Use of IV fluids may be beneficial in hypovolemic patients.
• The mainstay of monitoring equipment during CPR is electrocardiogram (ECG) and capnography (ETCO₂).

Arrest Rhythms

• The three most common arrest rhythms in dogs and cats are asystole, pulseless electrical activity (PEA) and ventricular fibrillation (V-fib).
• Asystole indicates complete cessation of electrical and mechanical heart activity.
• PEA indicates cessation of mechanical heart activity (lack of pulses) but continuation of electrical heart activity
• V-fib indicates uncoordinated mechanical heart activity.
• Capnography is the best indicator of chest compression efficacy and earliest indicator of ROSC.
• Due to the lack of a pulse and adequate pulse quality during CPA, monitoring tools such as pulse oximetry and indirect blood pressure devices are ineffective until ROSC has been achieved.
• Electrical defibrillation is the process in which the entire heart is depolarised and "reset". After defibrillation, the 2-minute BLS cycle restarts and ECG should not be evaluated until the end of the cycle.

Post-Cardiopulmonary Arrest Care

• ROSC is the resumption of a heartbeat, palpable pulse, or spontaneous breathing.
• PCA care requires dedicated one-on-one nursing to minimise the likelihood of CPA reoccurring and to maximise the likelihood of the patient recovering and going home.
• Unfortunately, many animals still perish despite CPR efforts. Statistics range from 35% to 44% of ROSC with only 6% survival to discharge.

CPR Positions and the Nurse's Role

• The positions nurses take part in during CPR are BLS rescuers (1 – chest compressor, 2 – airway manager/breather), ALS rescuer, and team leader.
• During a CPR event, using closed-loop communication is preferred Debriefing allows the team to talk and review their performance and team dynamics.
• Certification includes becoming certified as a RECOVER BLS Rescuer, RECOVER ALS Rescuer, or both.

This lesson provides an overview of the RECOVER CPR initiative, focusing on its goals, guidelines, and training for veterinary professionals. It covers essential topics such as the updated ABCs of CPR, the importance of advanced directives, and the need for regular refresher training. Students will learn where to access the RECOVER guidelines and the significance of hands-on CPR training.