J Vet Emergen Crit Care - 2012 - Brainard - RECOVER Evidence and Knowledge Gap Analysis On Veterinary CPR Part 5

Journal of Veterinary Emergency and Critical Care 22(S1) 2012, pp S65–S84
Special Article doi: 10.1111/j.1476-4431.2012.00751.x
RECOVER evidence and knowledge gap

analysis on veterinary CPR.
Part 5: Monitoring
Benjamin M. Brainard, VMD, DACVA, DACVECC; Manuel Boller, Dr. med. vet., MTR, DACVECC;
Daniel J. Fletcher, PhD, DVM, DACVECC and the RECOVER Monitoring Domain Worksheet
Authors
Abstract
Objective – To systematically examine the evidence on patient monitoring before, during, and following vet-
erinary CPR and to identify scientific knowledge gaps.
Design – Standardized, systematic evaluation of the literature, categorization of relevant articles according to
level of evidence and quality, and development of consensus on conclusions for application of the concepts to
clinical practice. Relevant questions were answered on a worksheet template and reviewed by the Reassessment
Campaign on Veterinary Resuscitation (RECOVER) monitoring domain members, by the RECOVER committee
and opened for comments by veterinary professionals for 3 months.
Setting – Academia, referral practice, and general practice.
Results – Eighteen worksheets evaluated monitoring practices relevant for diagnosing cardiopulmonary ar-
rest (CPA), monitoring CPR efforts, identifying return of spontaneous circulation (ROSC), and post-ROSC
monitoring.
Conclusions – Although veterinary clinical trials are lacking, experimental literature using canine models and
human clinical trials provided relevant data. The major conclusions from this analysis of the literature highlight
the utility of end-tidal carbon dioxide (EtCO2 ) monitoring to identify ROSC and possibly to evaluate quality
of CPR. In addition, recommendations for ECG analysis during CPR were addressed. Unless the patient is
instrumented at the time of CPA, other monitoring devices (eg, Doppler flow probe) are likely not useful
for diagnosis of CPA, and the possibility of pulseless electrical activity makes ECG inappropriate as a sole
diagnostic tool. Optimal monitoring of the intra- and postcardiac arrest patient remains to be determined
in clinical veterinary medicine, and further evaluation of the prognostic and prescriptive utility of EtCO2
monitoring will provide material for future studies in veterinary CPR.
(J Vet Emerg Crit Care 2012; 22(S1): 65–84) doi: 10.1111/j.1476-4431.2012.00751.x
Keywords: cardiac arrest, CPR, evidence
CPA cardiopulmonary arrest

Abbreviations CPP coronary perfusion pressure
AED automatic external defibrillator EGDT early goal directed therapy
AMSA amplitude spectrum area transformation EtCO2 end-tidal carbon dioxide
ETT endotracheal tube
LOE level of evidence
From the Department of Small Animal Medicine and Surgery, College of Vet- MAP mean arterial blood pressure
erinary Medicine, University of Georgia, Athens, GA 30602-7371 (Brainard);
Department of Clinical Studies, School of Veterinary Medicine, and the De- PCO2 partial pressure of CO2
partment of Emergency Medicine, School of Medicine, Center for Resusci- PEA pulseless electrical activity
tation Science University of Pennsylvania, Philadelphia, PA 19104 (Boller);
College of Veterinary Medicine, Cornell University, Ithaca, NY 14853-6401 PEEP positive end-expiratory pressure
(Fletcher). PICO population, intervention, control group,
RECOVER Monitoring Domain Worksheet Authors are listed in the Ap- outcome
pendix. RECOVER Reassessment Campaign on Veterinary Re-
The authors and collaborators declare no conflicts of interests. suscitation
Address correspondence and request for reprints to ROSC return of spontaneous circulation
Dr. Benjamin M. Brainard, College of Veterinary Medicine, University of
Georgia, Athens, GA 30602-7371. VF ventricular fibrillation
Email: brainard@uga.edu VT ventricular tachycardia
Submitted March 15, 2012; Accepted March 26, 2012.

C Veterinary Emergency and Critical Care Society 2012 S65
Brainard et al.
Vd alveolar dead space volume ture initiatives, the prioritized worksheet topics provide
Vt tidal volume excellent guidance for veterinary practitioners involved
in treating patients with CPA and represent a major step
for direction of further veterinary CPR research.
Introduction
The goals of a separate domain devoted exclusively Summary of the Evidence
to monitoring are 3-fold. First, because of the striking
differences in cardiovascular physiology during CPR Diagnosis of CPA and confirmation of endotracheal
compared to states of spontaneous circulation, special intubation
considerations apply to the use of familiar hemodynamic The first part of the monitoring domain investigates the
monitoring technology under these circumstances. Sec- diagnosis of CPA, and specifically addresses the criteria
ond, by recommending monitoring equipment and tech- to diagnose CPA in otherwise unresponsive, apneic pa-
niques necessary for the performance of high-quality tients prior to starting CPR. The modalities investigated
CPR, guidance for practitioners aiming to update clinical range from relatively simple procedures such as palpa-
CPR practices and preparedness is provided. Lastly, by tion of a femoral pulse to the utility of more advanced
highlighting deficiencies in the current literature specif- monitoring that may be more relevant for those animals
ically concerning evidence for monitoring protocols and that experience CPA during an anesthetic event, where
techniques during CPR, this document may provide a monitoring equipment is already in place. These ques-
source of future research hypotheses aimed toward im- tions touch on the conundrum that it is easier to rapidly
proving monitoring during veterinary CPR. diagnose life than death, and have been evaluated with
The monitoring domain is divided into 3 important as- the thought that the faster an accurate diagnosis of CPA
pects of veterinary CPR. The first is focused on methods can be made, the sooner CPR may be initiated. Surpris-
to confirm cardiopulmonary arrest (CPA) and endotra- ingly, there is little information available in the litera-
cheal intubation. The second section, and the bulk of this ture addressing the consequences of performing CPR on
domain, evaluates monitoring options during CPR, cov- patients who have not actually experienced CPA. Work-
ering both commonly used monitoring protocols as well sheets evaluated femoral pulse palpation (MON03), elec-
as newer options for assessing adequacy of CPR and re- trocardiography (MON05), absence of pulse identified
turn of spontaneous circulation (ROSC). The final section by a Doppler ultrasonic flow probe (MON04), and EtCO2
of this domain is concerned with suggested monitoring monitoring (MON02) for diagnosis of nonperfusing car-
protocols for small animal patients following ROSC. The diac rhythms or CPA.
key monitoring recommendations made in this consen-
sus statement for canine and feline CPR are as follows:
The value of pulse palpation for diagnosing CPA
r Time spent verifying an absent pulse may delay onset (MON03)
of CPR; chest compressions should be initiated imme- PICO Question
diately for apneic, unresponsive patients.
r ECG analysis of an unresponsive patient may help
In dogs and cats with suspected cardiac arrest (P), is
the palpation of femoral pulses (I) versus assessment
to rule out CPA, or be used to evaluate for rhythms
for other signs of life (eg, pupil size, agonal breathing,
requiring specific therapeutic approaches (eg, ventric-
thoracic auscultation) (C) a reliable tool for diagnosis of
ular fibrillation [VF]).
r End-tidal CO2 (EtCO2 ) should not be used as the sole
cardiac arrest (O)?
confirmation of endotracheal intubation in cardiac ar-
rest patients. Conclusion
r Pauses in chest compressions to evaluate the ECG
rhythm should be minimized. Evidence from many human studies (level of evidence
r EtCO2 monitoring is useful to identify ROSC, and may [LOE] 6) shows that lay rescuers and healthcare profes-
be prognostic for the likelihood of ROSC. sionals are often unable to accurately and swiftly deter-
r Patient monitoring following ROSC should be di- mine the presence or absence of a pulse. Palpation for
rected at identifying abnormalities that may portend a lack of a femoral pulse in dogs and cats is not a reli-
another CPA, and should be individually tailored to able diagnostic tool for cardiac arrest when used in the
each patient. absence of corroborating evidence such as apnea, agonal
breathing, or lack of an auscultable heartbeat. Moreover,
Although not all of the initial relevant questions in this the time needed to confirm the lack of a pulse may delay
domain could be addressed and remain material for fu- the initiation of CPR.
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RECOVER monitoring
Summary of the evidence perienced a cardiac arrest. In addition to assessment of

femoral pulses, palpation of metatarsal pulses and the
No clinical veterinary studies or experimental animal
apex beat should be evaluated.
studies have been conducted to investigate the reliabil-
ity of pulse palpation for diagnosis of cardiac arrest in
dogs or cats. Multiple, well-designed, prospective, ran- The utility of peripheral Doppler pulse evaluation for
domized human studies (LOE 6) have shown both diag- identification of CPA (MON04)
nostic inaccuracy and delayed diagnosis of the presence PICO Question
or absence of a pulse in adult and pediatric simulated
cardiac arrest.1–9 Studies used mannequins, healthy vol- In dogs and cats with suspected cardiac arrest (P), is
unteers, or patients on extracorporeal circulation with the evaluation of a Doppler pulse (I) versus assessment
pulsatile or nonpulsatile flow. The sensitivity and speci- for other signs of life (eg, pupil size, agonal breathing,
ficity of pulse palpation varied between studies, but was femoral pulse) (C) a reliable tool for diagnosis of cardiac
generally in the region of 0.9 (sensitivity) and 0.65 (speci- arrest?(O)
ficity). One study (LOE 6) separately analyzed the data
from pulseless patients, and found that only 2% of par- Conclusion
ticipants correctly recognized a pulseless patient within
10 seconds, suggesting that sensitivity may be much Loss of femoral pulse and radial artery Doppler signal
lower in the absence of a pulse.3 Another study found may occur before complete cardiac arrest. In addition,
that experienced doctors and nurses working in acute CPA events are often not predictable such that a Doppler
care areas were able to detect a pulse more quickly can be placed in advance, and valuable time may be spent
and accurately than those working in nonacute areas, attempting to locate an absent pulse with the Doppler
but confirmation of the absence of a pulse still required probe. Doppler pulse sounds are not a reliable tool for
longer than 10 seconds.8 Patient positioning may have the diagnosis of cardiac arrest, although their disappear-
an effect on the ability of a rescuer to palpate a carotid ance may indicate impending arrest in animals where
pulse.10 Human guidelines no longer recommend a pulse the Doppler probe was placed prior to CPA.
check (lay rescuer) or limit the permissible time for pulse
check to less than 10 seconds (healthcare provider) prior Summary of the evidence
to starting resuscitation efforts in unresponsive human
patients.11 In an experimental canine model (LOE 3) designed to de-
Human anatomy and the usual site of pulse palpa- tect pseudo-PEA (pulselsess electrical activity), femoral
tion are, however, different from those in cats and dogs. pulses and a radial artery Doppler signal were no longer
Most studies investigated palpation of the carotid pulse, detectable even though an esophageal Doppler signal
although the site was variable. In hypotensive infants, and thoracic aorta blood movement were still present,
however, palpation of the femoral pulse was more rapid and were lost an average of 100 seconds before aortic
and accurate than palpation of the carotid or brachial root fluctuations and esophageal Doppler sounds were
pulses for confirmation of a heartbeat.12 There are no no longer detectable.13 For this reason, loss of radial
studies investigating palpation of the femoral pulse dur- artery Doppler signal may be a clinically relevant means
ing cardiac arrest in any species. of detecting critical reduction of peripheral blood flow
Whereas there is good human evidence opposing and impending CPA. In clinical veterinary practice, CPA
pulse palpation for diagnosis of cardiac arrest, extrap- may not always be predicted in time to place a Doppler
olation to veterinary medicine should be cautious, given probe. In anesthetized patients, the loss of Doppler pulse
the differences in anatomy, site of pulse palpation, sounds may be a reasonable indicator of profound hemo-
arrest setting, and the training and specialization of dynamic deterioration or CPA.
veterinarians. Some human case reports (LOE 6) have described the
use of the radial Doppler pulse to monitor for events
such as PEA and verification of CPR-related blood flow,
although these studies do not address the actual diagno-
Knowledge gaps
sis of CPA.14–16
There is no information in the veterinary literature that
evaluates the accuracy of pulse detection using any spe-
Knowledge gaps
cific pulse location, whether performed by lay people or
those involved in veterinary care. Ideally, these studies Based on lack of clinical evidence, controlled animal
should be performed in animals with normo-, hyper-, studies in target species and clinical trials evaluating
and hypotension, as well as in patients who have ex- at-risk patients monitored by Doppler flow probe are

C Veterinary Emergency and Critical Care Society 2012, doi: 10.1111/j.1476-4431.2012.00751.x S67
Brainard et al.
recommended before Doppler pulse sounds can be con- arrest (tachycardia, bradycardia, ventricular ectopy) has
sidered a reliable tool for the diagnosis of CPA. been documented in the human literature via ambula-
tory electrocardiography, thus monitoring the ECG may
allow the veterinary team to anticipate CPA in suscepti-
The value of ECG assessment for confirmation of car-
ble patients (LOE 6).20
diac arrest (MON05)
PICO Question
Knowledge gaps
In dogs and cats with suspected cardiac arrest (P), is
the evaluation of an ECG (I) versus assessment for other Continued investigation into veterinary CPA ECG
signs of life (eg, pupil size, agonal breathing, femoral rhythms is indicated, as well as studies to evaluate if
pulse) (C) a reliable tool for diagnosis of cardiac arrest rapid ECG analysis (eg, as generated by "quicklook" de-
(O)? fibrillator paddles) can augment CPA diagnosis.
Conclusion The value of EtCO2 for diagnosing CPA (MON02)
Some ECG rhythms (eg, PEA) can easily be mistaken PICO Question
for perfusing rhythms, emphasizing the importance of In dogs and cats with suspected cardiac arrest (P), is the
accurate physical examination or additional monitoring evaluation of EtCO2 (I) versus assessment for other signs
modalities for the diagnosis of CPA. In addition to as- of life (eg, pupil size, agonal breathing, femoral pulse)
sessment for signs of life alone, ECG analysis enables (C) a reliable tool for diagnosis of cardiac arrest (O)?
identification of rhythms that can be treated with de-
fibrillation (eg, VF). In cases where the ECG rhythm is
Conclusion
consistent with CPA (eg, asystole or VF), the use of ECG
may help to clarify the status of a patient with clinical The correlation of cardiac output and EtCO2 during CPA
signs of CPA. In patients with syncope or collapse but has been demonstrated in animal models and human
not CPA, ECG may assist in ruling out CPA. clinical studies. At constant ventilation, a rapid decline
in EtCO2 value is expected during the evolution of CPA
such that a sudden decrease of EtCO2 to near zero in in-
Summary of the evidence
tubated, consistently ventilated animals is a strong indi-
There is little evidence in the veterinary literature that cator of CPA. In nonintubated patients, different causes
directly addresses the value of evaluating the ECG ver- of CPA (asphyxial versus primary cardiac), may alter the
sus other signs of life for diagnosing cardiac arrest. Cer- EtCO2 level detected immediately following intubation,
tain cardiac arrhythmias (eg, PEA, pulseless ventricular with the EtCO2 frequently normal or elevated in asphyx-
tachycardia [VT]) that may appear to be consistent with ial CPA. Consequently, the initial EtCO2 value cannot be
a perfusing rhythm but, in fact, are not, may delay the used alone to diagnose CPA. Subsequent EtCO2 values,
onset of CPR while additional verification of CPA is ob- however, will rapidly decrease after the first few deliv-
tained. Since CPA is a clinical diagnosis, it is essential that ered breaths unmasking the presence of CPA.
the ECG is not regarded as the sole indicator of life or of
a perfusing cardiac rhythm. Given the difficulty in diag-
nosing CPA using pulse palpation alone (see MON03),
ECG analysis may help to more rapidly alert the care- The correlation of EtCO2 with cardiac output has been
giver to CPA. In the anesthetized patient (LOE 2 and 4), shown in many animal and human studies (LOE 3 and
where physical signs of CPA such as unconsciousness 6),21–28 and may be a better reflection of cardiac out-
and apnea are not available, and where the animal is put than arterial blood pressure (LOE 3).29 In a canine
likely monitored with an ECG prior to CPA, ECG alter- model of cardiac arrest (LOE 3), EtCO2 was documented
ations may prove helpful as a supporting diagnostic tool to quantitatively reflect cardiac output when minute ven-
for confirmation of CPA.17, 18 tilation was held constant.21 At the onset of cardiac ar-
In cases of animals with syncope or collapse not as- rest, EtCO2 fell immediately to near zero. During car-
sociated with CPA, ECG findings may aid in diagnosis. diopulmonary resuscitation, EtCO2 increased with on-
One LOE 4 study described the use of an implantable set of chest compressions. A sudden, large rise of EtCO2
ECG loop recorder in dogs with syncope, collapse, or occurs at ROSC (LOE 3 and 6).21, 30,31 Although EtCO2 is
intermittent weakness and identified a variety of cardiac also affected by ventilation parameters, the linear rela-
rhythms such as slow ventricular escape and supra-VT.19 tionship of EtCO2 and cardiac output was consistently
Cardiac activity that is premonitory of sudden cardiac observed in porcine CPA models (LOE 6).23,32–37 This
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RECOVER monitoring
has also been demonstrated in a number of human case Confirmation of endotracheal intubation (MON06)
studies (LOE 6), in which EtCO2 also inversely correlated A patent airway is essential for supporting oxygenation
to systemic oxygen extraction ratio, which served as an and ventilation during CPR, and guidelines are neces-
indicator of tissue oxygen delivery.22,38–40 Additionally, sary to verify endotracheal intubation (as opposed to
EtCO2 correlates with coronary perfusion pressure (CPP) esophageal intubation) in the context of CPR. The util-
during CPR (LOE 3).41, 42 Therefore, EtCO2 may be used ity of capnometry to confirm endotracheal intubation in
as an index of cardiac output and aid in detecting circu- humans, dogs, and cats with intact circulation is well es-
latory arrest. tablished; however, the extent to which the same is true
There are important limitations to the utility of EtCO2 in dogs and cats with CPA is less clear.49
to diagnose CPA, however. EtCO2 immediately follow-
ing intubation varies depending on whether CPA is of
asphyxial or primary cardiac origin. In a canine asphyx- PICO Question
ial arrest model (LOE 3), the initial mean EtCO2 (35.0 ± In dogs and cats with cardiac or respiratory arrest (P),
15 mm Hg) was higher than the prearrest mean EtCO2 is the use of EtCO2 monitoring (I) versus observance of
level (31.9 ± 4.3 mm Hg).43, 44 Subsequent EtCO2 val- chest wall motion (c) a more accurate tool for verification
ues in this cohort were lower during cardiopulmonary of endotracheal intubation?
resuscitation (mean EtCO2 of 12.4 ± 3.5 mm Hg during
CPR) but rapidly increased to a mean EtCO2 of 27.0 ± 7.2
mm Hg immediately prior to or at ROSC.44 These find- Conclusion
ings were mirrored in a study of human patients (LOE 6)
comparing subjects with asphyxial cardiac arrest (mean Verification of endotracheal tube (ETT) placement in
initial EtCO2 of 66.4 ± 17.3 mm Hg) with those with dogs and cats with cardiac or respiratory arrest is best
cardiogenic cardiac arrest (mean initial EtCO2 of 16.5 ± accomplished using a combination of clinical assessment
9.2 mm Hg).45 Studies of porcine CPA models (LOE 6) (ie, direct visualization of the ETT between the ary-
further confirmed these observations.46 Other conditions tenoid cartilages, auscultation of air movement in both
may lead to a sudden decline in EtCO2 values in the ab- hemithoraces, observation of chest wall motion, or ETT
sence of CPA. For example, the presence and severity of condensation) and secondary confirmatory tools such
pulmonary embolism has been correlated to a decrease in as EtCO2 monitoring. In patients where a high EtCO2
EtCO2 in dogs undergoing total hip replacement surgery value is obtained following intubation, endotracheal in-
(LOE 2)47 and in experimental rodent cardiac arrest mod- tubation is likely, due to the low amount of CO2 in the
els (LOE 6).48 stomach and esophagus.
EtCO2 is a useful index of pulmonary blood flow
and cardiac output in endotracheally intubated ani-
mals receiving constant ventilation. In conjunction with
physical examination findings, it may aid in early de- Eleven studies in nontarget species (all LOE 6) docu-
tection of CPA in these animals. In animals endotra- ment concern for the use of EtCO2 monitoring alone (via
cheally intubated and ventilated after CPA (or as part capnography or colorimetric indicator devices) when
of CPR), the initial EtCO2 value may not reliably cor- verifying proper ETT position during cardiac arrest.50–60
relate with cardiac output, particularly in the setting of One human study (LOE 6) documented that ausculta-
asphyxial arrest. Therefore, best evidence suggests that tion (not chest wall motion) for verification of ETT posi-
EtCO2 cannot be used as the sole modality to diagnose tion was superior to EtCO2 monitoring in cardiac ar-
CPA. rest patients.52 However, another human study (LOE
6) demonstrated no significant difference between the
use of capnography and auscultation to confirm ETT
Knowledge gaps
placement in patients during CPR.61 One experimental
Although at least 1 veterinary CPR study has noted peak study (LOE 3) confirmed the ability of EtCO2 to identify
EtCO2 during resuscitation, values obtained at the ini- esophageal intubation in dogs undergoing CPR.62
tiation of CPR have not been reported, nor have they Although the preponderance of studies verified cor-
been classified by the cause of CPA.18 Prospective stud- rect ETT placement using primary clinical assessments
ies should aim to verify experimental findings (eg, the (including direct visualization of the ETT between the
difference between asphyxial and primary cardiac ar- vocal cords, observation of chest rise, presence of breath
rest) in clinical veterinary patients, and endeavor to clar- sounds on bilateral auscultation of lung fields, absence
ify the utility of EtCO2 in early accurate recognition of of breath sounds over the epigastrium, and presence
CPA. of condensation in the ETT), there are no studies that

Brainard et al.
directly compared EtCO2 measurement to these clinical during CPR, MON11 and MON12 discuss the applica-
assessments. tion of these techniques, especially in the context of in-
In patients with respiratory but not cardiac arrest, terruptions in chest compressions. The remaining ques-
esophageal intubation is not expected to produce a sus- tions regarding monitoring during CPR are focused on
tained high EtCO2 value, and in this context, EtCO2 mon- improvement of CPR outcome, including the monitoring
itoring may be used to verify ETT position. Two human of physiologic feedback and EtCO2 (MON15, MON23),
studies (LOE 6) support this conclusion.51, 52 In an ad- ventilatory parameters (MON19), general feedback on
ditional study (LOE 6), the use of EtCO2 for ETT ver- the quality of CPR mechanics (MON16), blood gases
ification was reliable for confirming ETT placement in (MON20), and blood electrolytes (MON21). In addition,
patients with respiratory distress or arrest.58 a final question addressed the utility of ECG wave-
In patients with cardiac arrest, a low EtCO2 value form analysis as a predictor of successful defibrillation
may be encountered despite appropriate ETT placement, (MON24).
and may not distinguish endotracheal from inadvertent
esophageal intubation. This is supported by the majority
The relevance of ECG monitoring during CPR
of studies assessed (LOE 6).50,52–54,56–59,63–65 In contrast,
(MON14)
2 small human studies (LOE 6)66, 67 and 1 experimental
canine study (LOE 3)62 obtained a high test sensitivity, PICO Question
supporting the use of EtCO2 monitoring for verifying In dogs and cats in cardiac arrest (P), does the use of
endotracheal intubation in subjects with CPA. None of ECG monitoring during CPR (I), compared with no ECG
the dogs with esophageal intubation achieved an EtCO2 monitoring (C), improve outcome (eg, ROSC, survival to
value above 11 mm Hg at any time during CPR, while discharge) (O)?
all endotracheally intubated animals achieved an EtCO2
value of 13 mm Hg or higher.61
In summary, there is not sufficient evidence to support Conclusion
the superiority of a single observation or measurement, Given the available evidence, the ECG should be utilized
such as EtCO2 , for verification of ETT placement in dogs to identify and treat arrhythmias amenable to defibrilla-
or cats with CPA. Generally, the sensitivity of EtCO2 tion (pulseless VT and VF) during CPR. As the majority
monitoring for identification of endotracheal intubation of the veterinary patient population has an initial ar-
in patients with CPA is low. In small animal patients, rest rhythm of PEA or asystole that may convert to VF
visualization of the ETT between the arytenoid carti- during CPR, ECG monitoring beyond documentation of
lages may be less difficult than in humans and would be the first identified rhythm may be of benefit.18 However,
considered positive confirmation of endotracheal intu- ECG monitoring should be weighed against the risk of
bation. interrupting chest compressions for ECG analysis (see
MON11).
Knowledge gaps
Despite physiologic similarities, evidence regarding the Summary of the evidence
evaluation of successful endotracheal intubation using There are no studies that directly investigate the outcome
EtCO2 with or without confirmatory physical parame- effect of ECG usage during CPR in animals or people. The
ters is absent in both healthy small animal patients and 2000 American Heart Association CPR guidelines for pe-
those with cardiovascular collapse or CPA. diatric advanced life support recommend the use of ECG
monitoring for detection of arrhythmias, and subsequent
modifications of the guidelines (2005, 2010) make rec-
Monitoring during CPR
ommendations for treatment of cardiac arrhythmias.68
A large part of the monitoring domain focused on recom- Three studies (all LOE 6) demonstrate a better outcome
mendations for assessments that should be performed when CPR is performed in adult humans presenting with
during CPR, as well as for the appropriate application of an initial arrhythmia of VF or pulseless VT both in- and
these techniques. Because these modalities are inextrica- out-of-hospital.69–71
bly linked to other worksheets across the Reassessment Continuous monitoring of an ECG during CPR may
Campaign on Veterinary Resuscitation (RECOVER) do- be useful to detect conversion to a rhythm that can be
main (eg, in order to treat VF, it must first be identi- treated with defibrillation. The majority of studies in hu-
fied by electrocardiography), some cross-referencing is mans have shown higher survival rates for patients with
necessary across the RECOVER report. While MON14 initial nonshockable rhythm (ie, rhythm not amenable
addresses the question of the utility of ECG monitoring to defibrillation) and subsequent conversion to VF/VT
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RECOVER monitoring
followed by successful defibrillation (LOE 6),72–74 al- 61 human out-of-hospital cardiac arrests found that chest
though 1 study opposed this finding (LOE 6).75 compressions were provided for an average of only 40%
Evidence is mixed regarding outcome associated with ± 21% of the first 5 minutes during resuscitation by
ECG monitoring during CPR beyond determination of trained rescuers.80
the presenting rhythm and the associated benefit of early
defibrillation. The delay or interruption in chest com-
Knowledge gaps
pressions that occur to allow setup and review of the
ECG trace during CPR must also be considered (see Further research is indicated to better describe the oc-
MON11). currence of interruptions in chest compressions in vet-
erinary CPR, and delineate the causes and the effects of
interruptions in chest compressions, including specific
Knowledge gaps information on the effect of pauses on ROSC and neuro-
The effect of ECG monitoring on CPR outcome in small logic outcome.
animal patients has not been clearly identified. Many
veterinary practices have ECG equipment.76 Definitive
The effects of hands-off time for rhythm check after
study of the frequencies of heart rhythms during CPR
defibrillation (MON12)
and their association with outcome merits further study.
Specifically, the role of intraarrest occurrence of VF in pa- PICO Question
tients with nonshockable initial rhythms demands fur- In dogs and cats with cardiac arrest (P), does the mini-
ther investigation. mization of hands-off time after defibrillation for rhythm
check (I), as opposed to standard care (C), improve out-
Interruption of chest compressions for rhythm check come (O) (eg, ROSC, survival)?
(MON11)
PICO Question Conclusion
In dogs and cats undergoing resuscitation for cardiac ar- Extrapolation of human research to veterinary patients
rest (P), does the interruption of CPR to check circulation remains difficult as many human studies investigate the
or ECG rhythm (I), as opposed to no interruption of CPR use of equipment such as automatic external defibrilla-
(C), improve outcome (O) (eg, ROSC, survival)? tors (AEDs) that have not been used in veterinary CPR.
There are not enough data in the human literature to
definitively support the hypothesis that minimization of
Conclusion hands-off time after defibrillation for rhythm check im-
Although primary VF remains a rare cause of CPA in proves CPR outcome (defined either as ROSC or survival
veterinary patients, evaluation of the ECG is valuable to discharge). It seems prudent to resume chest compres-
for identification of a shockable rhythm that develops sions as soon as possible after defibrillation and rhythm
as a consequence of CPR efforts. Despite this, it seems identification.
prudent to avoid or minimize interruptions in chest com-
pressions in dogs and cats during CPR efforts.
Several experimental animal and clinical human studies
(1 LOE 3 and 9 LOE 6 studies) have found that minimiza-
Interruption of CPR efforts for any reason does not im- tion of hands-off time after defibrillation improves out-
prove outcome (majority LOE 6, 1 LOE 3).77–85 One study come (ROSC, survival), leading to recommendations that
in swine (LOE 6) revealed that continuous chest com- the interval between discontinuation of chest compres-
pression CPR produces greater neurologically normal sions and delivery of a shock should be kept as short as
24-hour survival than standard CPR.79 Recommenda- possible.77, 80,85–92 Interruptions following defibrillation
tions (LOE 6) have been made that providers performing may arise from rescuer change out, mandatory delay
chest compressions switch out every 2 minutes to min- with AED use, or attempted adherence to CPR guide-
imize rescuer fatigue, but that they minimize no-flow lines.
time during the switch.82, 85 It may take up to 2 minutes of mechanical CPR
Significant pauses in chest compressions have been to reestablish adequate CPP following interruptions of
documented as a result of endotracheal intubation, ECG CPR (LOE 6).86 Adequate heart massage before and
analysis, or other activities associated with airway man- during defibrillation greatly improved the likelihood
agement (eg, suctioning).83, 84 Another study (LOE 6) of of ROSC in 1 study of porcine VF (LOE 6).86 Four

Brainard et al.
experimental studies in swine (LOE 6) were neutral re- The effect of physiological feedback monitoring on
garding the effect on resuscitation success of duration quality of CPR (MON15)
of hands-off time following defibrillation.79,93–95 One of PICO Question
these studies found that resuscitation success lies more
in the quality of chest compressions than hands-off time For dogs and cats requiring resuscitation (P), does the
(LOE 6).94 One human clinical study identified an asso- use of physiological feedback regarding CPR quality
ciation between shallow chest compressions with longer (eg, EtCO2 monitoring, blood gas analysis) (I), compared
preshock pauses for rhythm analysis and defibrillation with no feedback (C), improve any outcomes (eg, ROSC,
failure (LOE 6).89 It has been documented, however, that survival) (O)?
short interruption of chest compressions (8 seconds) re-
quired for rhythm analysis and defibrillation resulted in
adequate postresuscitation myocardial and neurologic Conclusion
function in swine (LOE 6).93 Of practical interest, in a ret- No research was identified that directly examined the
rospective study of adult human patients with recurrent effect of physiological feedback devices on the outcome
VF (LOE 6), VF recurred within 6 seconds of successful of resuscitation. However, there is evidence that docu-
defibrillation in only 20% of patients, while recurrent VF ments the value of EtCO2 on prognostication and early
had developed in 72% of patients by 60 seconds.96 This identification of ROSC, as well support for its use as
implies that a rhythm check immediately following de- surrogate measure of CPP during CPR.
fibrillation may not result in an accurate determination
of defibrillation success, and it may be better practice
to continue CPR immediately following the shock, with
a short pause for rhythm analysis after completion of a
2-minute cycle of CPR. Only 1 veterinary study is available that provides infor-
Most recently a relationship between early postdefib- mation on prognostic indicators for CPA in dogs and
rillation chest compression and refibrillation rate was cats undergoing nonexperimental arrests (LOE 2).18 The
established, which could emerge as a potential argu- mean highest recorded EtCO2 was significantly higher
ment against immediate resumption of chest compres- in dogs that achieved ROSC (36.6 ± 19.7 mm Hg) than
sions after defibrillation. In humans with out-of-hospital those that did not (10.3 ± 10.2 mm Hg); however, the
cardiac arrest, an 8-second (range: 7–9 sec) versus a 30- difference was not significant in cats. Ninety-four per-
second (range: 21–39 sec) pause after successful defib- cent of the dogs that did not achieve ROSC had maximal
rillation before the resumption of chest compressions EtCO2 values of <15 mm Hg, whereas 86% with values
was compared.97 While the overall recurrence of VF was ≥15 mm Hg achieved ROSC. In cats, ROSC was achieved
the same in both cohorts, VF reoccurred earlier in the in 90% with peak EtCO2 of ≥20 mm Hg, but in only 55%
patients who received early resumption of chest com- with values <20 mm Hg. The value of EtCO2 as predictor
pressions, potentially resulting in a longer duration of of ROSC is a finding echoed by clinical research in hu-
untreated VF until subsequent rhythm check and defib- mans (LOE 6).98, 99 Two studies have shown that EtCO2
rillation. However, patient outcome was not reported in values correlate with CPP during CPR and thus provide
this study, and the overall relevance to veterinary CPR real-time physiologic feedback during CPR. Kern et al
is unclear. used an experimental canine VF model (LOE 3) to eval-
uate EtCO2 as a prognostic guide for resuscitation.42 A
decline in EtCO2 was seen during CPR in the dogs in
which ROSC was not obtained, while EtCO2 remained
constant in the dogs that were successfully resuscitated.
EtCO2 was also significantly correlated to CPP, which
Knowledge gaps
was found to be a good predictor of outcome. A porcine
The impact of pauses in CPR following defibrillation has VF model of CPA (LOE 6) showed significantly higher
not been critically evaluated in dogs or cats, and studies EtCO2 and PaCO2 values in surviving animals after 6
evaluating immediate versus delayed rhythm diagnosis minutes of CPR (18 ± 7 versus 5 ± 4 mm Hg).34 In this
may be indicated prior to studies that evaluate different study, changes in EtCO2 and PaCO2 occurred in parallel
delay times prior to the resumption of CPR. Importantly, and correlated with CPP. When ventilation is held con-
having a CPR reporting system and template in place stant, EtCO2 may provide information regarding ROSC.
that includes recording of chest compression pauses will In a pediatric dog model of CPA (LOE 3), the mean EtCO2
be essential to answer some of these questions in veteri- during CPR was 12.37 ± 3.5 mm Hg and suddenly in-
nary medicine. creased to 27 ± 7.2 mm Hg at or just prior to ROSC.43
S72
RECOVER monitoring
Knowledge gaps Knowledge gaps

Objective data on the effects of physiologic feedback on Optimal cutoff values for EtCO2 that may improve the
CPR quality and success are lacking in the human and likelihood of ROSC when used as a feedback goal have
veterinary literature. The effect of real-time feedback (eg, not been determined in veterinary medicine.
EtCO2 ) on parameters such as depth of chest compres-
sion or CPR success will be important to evaluate in
future studies. The importance of audio-visual feedback on CPR de-
livery characteristics (MON16)
PICO Question
The effect of EtCO2 monitoring on ROSC (MON23) For dogs and cats in cardiac arrest (P), does the use of
PICO Question feedback regarding the mechanics of CPR quality (eg,
rate and depth of compressions and/or ventilations) (I),
In dogs and cats in cardiac arrest (P), does the use of compared with no feedback (C), improve any outcomes
EtCO2 monitoring during CPR (I), compared with no (eg, ROSC, survival) (O)?
EtCO2 monitoring (C), improve chances for ROSC (O)?
Conclusion
Conclusion There is no direct evidence that feedback about the me-
EtCO2 measurement serves as a noninvasive surrogate chanics of CPR quality affects outcome in dogs and cats,
measurement of cardiac output and CPP during CPR. or that current methodology is applicable to veterinary
EtCO2 is frequently used as a reflection of quality of species. Studies in humans do not show a clear benefit
CPR when comparing approaches or devices. Rescuers of the use of real-time feedback monitoring in terms of
can and likely should alter circulatory support methods outcome improvement, although such technology was
to optimize EtCO2 values. No study has been performed shown to improve adherence to CPR guidelines.
comparing the use of a capnometer during CPR to CPR
without a capnometer. Specific target values for EtCO2 Summary of the evidence
are addressed in MON 22.
Newer defibrillators can record and report on data about
the depth, rate, and decompression (recoil) time of chest
compressions using accelerometers, force transducers,
or induction of ECG artifacts via sternal movements.
The monitoring of EtCO2 during CPR gives information Ventilation data may be derived from changes in tho-
regarding cardiac output and cardiac index (LOE 3 and racic impedance or from integrated capnography. Real-
6),32, 35,100 CPP (LOE 3 and 6),41, 42,101, 102 and mean aortic time feedback from these defibrillators usually consists
pressure (LOE 6)101 during CPR. Studies focusing on the of verbal messages and/or visual prompts displayed on
utility of EtCO2 monitoring for predicting CPR outcome the monitor.
(primarily evaluating adult humans with nontraumatic, Most human studies that evaluated the effect of real-
primary cardiac arrest [LOE 6]), uniformly found that time feedback on ROSC were neutral in outcome. One
patients with higher EtCO2 over the course of CPR were large study (LOE 6) investigated a defibrillator that pro-
more likely to achieve ROSC, survival to hospital dis- vided audio-visual prompts regarding adequacy of chest
charge, or both.22, 32,33, 39,45, 56,58, 98,99, 101,103–114 Only a sin- compressions and ventilation in human adults with out-
gle indexed study (LOE 6) was neutral on the subject of of-hospital cardiac arrest.115 While the authors found
EtCO2 monitoring pertaining to CPR outcome, finding that compliance with CPR guidelines and quality of CPR
no difference between EtCO2 in CPA patients that could (eg, number and depth of chest compressions) was im-
not be resuscitated (13.7 ± 7 mm Hg) and EtCO2 in CPA proved, the study failed to identify a positive effect on
patients that achieved ROSC (12.9 ± 5 mm Hg).31 either ROSC or hospital discharge. A smaller study (LOE
There is sufficient evidence to support the routine use 6) evaluating in-hospital CPA also failed to demonstrate
of capnometry during CPR. Higher EtCO2 values are a difference in ROSC or hospital discharge using a simi-
associated with higher cardiac output and CPPs, and are lar defibrillator feedback protocol.116
strongly associated with ROSC in people. Thus, targeting A prospective human study (LOE 6) that evaluated a
a specific EtCO2 value by optimizing CPR technique is defibrillator that provided real-time prompts when chest
likely to benefit patients and improve the likelihood of compression parameters (rate, depth, or duty cycle) and
ROSC. ventilation parameters (rate, depth, or inspiration time)

Brainard et al.
were not in accordance with guidelines failed to show a Summary of Evidence

statistically significant difference in survival, but showed
Higher EtCO2 values are associated with an
a trend toward a benefit for the use of real-time feedback
increased likelihood of ROSC (LOE 3 and
(hospital discharge 2.9% for control versus 4.3% with
6).32, 33,38, 39,41, 99,103, 106,119, 120 Persistently low EtCO2
feedback).117 In this study, some CPR variables such as
during CPR is associated with a poor prognosis (LOE
compression depth, percentage of compressions with ad-
3 and 6).42, 46,111 In a single study of humans with CPA
equate depth, and respiratory rate were significantly im-
(LOE 6), survivors to hospital discharge had higher
proved with feedback.
EtCO2 during resuscitation than nonsurvivors.103
A recent study compared the use of limited CPR feed-
In a cardiac arrest model in swine (LOE 6), piglets that
back (metronome and visual graphics of the depth of
did not achieve ROSC had EtCO2 readings that remained
chest compressions) with more extensive feedback that
below 15 mm Hg for the duration of CPR.46 In an exper-
integrated verbal prompts during CPR.118 There was no
imental canine study (LOE 3), the EtCO2 increased from
change in CPR quality or rate of ROSC with the addition
13.9 ± 4 mm Hg during CPR to 27 ± 7 mm Hg at or just
of the voice prompts.
prior to ROSC.44 In another experimental study in dogs
(LOE 3), 6 of the 12 dogs were successfully resuscitated,
and the dogs with ROSC achieved a mean EtCO2 of 9.6
± 3.2 mm Hg during CPR versus 3.2 ± 1.1 mm Hg for
Knowledge gaps
dogs that did not achieve ROSC.41
Randomized prospective studies using metronomic Absolute values for EtCO2 that might be predictive
guidance of chest compression rates are feasible in veteri- of ROSC have been most closely examined in human
nary medicine and merit investigation. Additional stud- studies (all LOE 6). Cantineau and colleagues concluded
ies evaluating the use of accelerometers or other meth- that an EtCO2 value of greater than 10 mm Hg obtained
ods to quantify depth and rate of chest compressions during the first 20 minutes of CPR predicted ROSC
may result in data that can be integrated into a real-time with a sensitivity of 100% and specificity of 66%.106
feedback system suitable for veterinary CPR. Moreover, In 2 other human studies, EtCO2 values consistently
such systems would provide an opportunity to record less than 10 mm Hg during CPR predicted failure to
and analyze rescuer performance, and could be the ba- achieve ROSC.99, 111 Compared to these studies, Asplin
sis for studying CPR quality in clinical settings and for and White reported much higher maximum EtCO2 lev-
training purposes. els in human patients that did not achieve ROSC (22.7
± 8.8 mm Hg), although these values were significantly
lower than those in survivors (30.8 ± 9.5 mm Hg).120
Another small observational study showed that all sub-
The role of EtCO2 in predicting ROSC (MON22) jects that achieved ROSC had measured EtCO2 values
PICO Question above 10 mm Hg during CPR, although several of those
In dogs and cats in cardiac arrest (P), does an EtCO2 who did not survive also had EtCO2 values greater than
value above 15 mm Hg during CPR (I), compared with 10 mm Hg.103
an EtCO2 value below 15 mm Hg (C), predict ROSC (O)? The administration of sodium bicarbonate during CPR
can increase the EtCO2 independent of cardiac out-
put and coronary perfusion.121 An experimental canine
study of VF (LOE 3) described CPPs that were highly cor-
Conclusion related to EtCO2 during CPR prior to the administration
of epinephrine but not afterward.122 This was also found
EtCO2 values are positively correlated with CPP and
in another study (LOE 3), where EtCO2 was not different
rise steeply when ROSC occurs. Higher levels appear
between nonresuscitated and resuscitated animals.123
to predict ROSC while continued low EtCO2 predicts
Despite these findings, epinephrine was used during
nonsurvival. In humans, an EtCO2 less than 10 mm Hg
CPR in several human observational clinical trials111 and
over a period of several minutes during CPR is a poor
in one of the canine research studies102 without reducing
prognostic indicator for ROSC. However, studies have
the prognostic value of EtCO2 on ROSC.
shown variability in exact changes in EtCO2 measure-
ments based on the underlying cause of cardiac arrest
and medications used during resuscitation. Caution may
Knowledge gaps
be warranted when interpreting a rise in EtCO2 after
using either sodium bicarbonate or epinephrine during While there is evidence that EtCO2 is a reliable indicator
CPR. of ROSC when it occurs, and that higher peak EtCO2
S74
RECOVER monitoring
values during CPR are associated with ROSC in dogs, Administration of high ventilation rates is a common
there are no prospective studies that evaluate the change occurrence during CPR (LOE 6) and can result in per-
in EtCO2 values during CPR in clinical veterinary pa- sistent positive intrathoracic pressure and a significant
tients, or definitively identify a cut-off point or goal for decrease in CPP.128, 129 Hyperventilation can result in de-
measured EtCO2 during a CPR episode. These data also creased ROSC (LOE 6), with 1 study showing a 69%
need to be reevaluated in cats. decrease in the rate of ROSC between pigs ventilated at
30 breaths/min compared to 12 breaths/min.129
The measurement and provision of positive end-
The importance of monitoring ventilation during CPR expiratory pressure (PEEP) may be indicated, and 1
(MON19) study in rats suggested that 5 cm H2 O PEEP during
PICO Question CPR may result in greater survival rates compared with
zero end expiratory pressure (LOE 6), although this tech-
For dogs and cats requiring resuscitation (P), does the
nique also increases intrathoracic pressure.130
monitoring and control of ventilatory parameters (eg,
ventilation rate, minute ventilation, and/or peak pres-
sures) (I), as opposed to standard care (without ventila- Knowledge gaps
tory monitoring) (C), improve outcome (O) (eg, ROSC,
Data regarding respiratory rates and compres-
survival)?
sion:ventilation ratios should be confirmed in small ani-
mal patients, in addition to further studies evaluating the
effects of different Vt and PEEP. Moreover, pulmonary
Conclusion
gas exchange and respiratory mechanics during CPR are
Alterations in ventilation parameters (ventilation rate, not well understood and deserve further exploration.
compression:ventilation ratio, end expiratory pressure)
may have significant effects on ROSC, survival, and
hemodynamics; however, strong evidence on the effect Monitoring arterial and venous blood gases during
of monitoring ventilatory parameters on outcome is lack- CPR (MON20)
ing and research in small animal patients is absent. High PICO Question
ventilation rates (greater than 10–12 breaths/min) dur- In dogs and cats with cardiac arrest (P), does the mea-
ing CPR should be avoided, as time spent without car- surement of arterial blood gases during resuscitation (I)
diac compressions in single-rescuer scenarios and in- versus measuring venous blood gases (C) improve the
creased time with positive intrathoracic pressure will chances of ROSC (O)?
have a negative effect on hemodynamics. Optimal ven-
tilation rates are unknown.
Excessive ventilation during CPR commonly occurs, Conclusion
even with trained personnel, and retraining results in Venous blood gas values have better predictive value
minimal improvement. Because of this fact, and because for ROSC than arterial blood gas values and are directly
traditional tidal volume (Vt ; eg, 10 mL/kg) may not be related to physiological properties such as cardiac output
necessary during CPR, the monitoring and control of and tissue perfusion.
ventilatory parameters may be beneficial in small animal
patients during CPR.
Blood gas analysis (arterial or venous) during CPR is
controversial due to the clinical paradox that results in
Only 1 LOE 3 study was identified,124 and this, in ad- relatively normal blood gas values early in CPA despite
dition to several LOE 6 studies,78, 125,126 was focused on significant hypoperfusion of tissues (LOE 6).131 An eval-
evaluation of compression:ventilation ratios, providing uation of the association between arteriovenous partial
limited information on other ventilation parameters. pressure of CO2 (PCO2 ) difference and cardiac output
One study in swine (LOE 6) compared animals receiv- during CPR in dogs (LOE 3) found that mixed venous
ing a Vt of 12.5 ± 0.6 mL/kg to those receiving 50% of PCO2 and pH was better associated with low cardiac out-
that Vt during CPR, and did not demonstrate a differ- put states than arterial values.132 A laboratory evaluation
ence in ROSC between groups.127 Lower tidal volumes of arterial and venous blood gas, pH, and lactate changes
will reduce peak airway pressure during CPR (LOE 6), in dogs during CPR (LOE 3) found that mixed venous
and measurement of Vt may lead to more focused rec- blood gas values changed to a greater degree during the
ommendations for small animal CPR.128 resuscitation period than did the arterial samples.133 A

Brainard et al.
significant arteriovenous difference in pH, PCO2 , and surement of serum electrolytes may allow directed ther-
PO2 was found during CPR in this group of dogs, and apy in addition to standard CPR. Ionized hypocalcemia
supported the premise that venous values more accu- may be prognostic for ROSC. The imperative for therapy
rately reflect tissue acid-base balance than arterial values. of other electrolyte abnormalities that occur during CPR
A swine CPA model (LOE 6) showed similar results.131 is less clear. The measurement of electrolytes in certain
Venous pH also was found to have a greater predictive cases may identify abnormalities that, if corrected, may
value for defibrillation outcome in dogs compared to ar- promote ROSC.
terial pH (LOE 3),134 and in humans with CPA secondary
to severe hypothermia (LOE 6).135
The value of arterial blood gases is less clear. A study Summary of the evidence
evaluating arterial blood gases in dogs undergoing var- Ionized hypocalcemia can occur during prolonged car-
ious resuscitation techniques (LOE 3) found that sur- diac arrest and resuscitation in dogs (LOE 3).140 Another
viving dogs had lower arterial pH and higher PaCO2 laboratory investigation of canine CPR (LOE 3) found
during CPR compared to dogs that did not survive.123 that arterial ionized calcium decreased within 5 minutes
However, a clinical study in humans (LOE 6) showed the of starting CPR and continued to decrease in dogs that
opposite, that patients with CPA who did not experience could not be resuscitated.137 Other studies of ionized cal-
ROSC had significantly lower arterial pH and higher cium levels during canine CPR (LOE 3) did not identify
PaCO2 than patients that achieved ROSC.136 Due to the ionized hypocalcemia (LOE 3).141
delay between initiation of CPR and blood sampling, this Potassium levels can increase during CPR, and
study primarily confirms that prolonged and worsening marked hyperkalemia (>8.0 mmol/L) was associated
elevations of PaCO2 are associated with lower rates of with lack of ROSC in both dogs (LOE 3)137 and pigs (LOE
ROSC in human CPR. In addition, another canine model 6).142 A small human study evaluating the efficacy of
of CPR (LOE 3) did not find significant associations be- hemodialysis during CPR for treatment of severe hyper-
tween arterial blood gas values and ROSC.137 The same kalemia found that ROSC was achieved in all 3 patients
was true in cats (LOE 3).138 Thus, the value of arterial once the mixed venous potassium was decreased be-
blood gas abnormalities for quality assessment or prog- low 8.0 mmol/L (LOE 6), which suggests that treatment
nostication of CPR success remains unclear. Even after of hyperkalemia during CPR may improve resuscitative
ROSC, arterial base excess was not an independent pre- efforts.143 In the special circumstance of hypothermia-
dictor of mortality in resuscitated patients, but merely associated CPA, severe hyperkalemia may indicate that
correlated with duration of CPR (LOE 6).139 cardiac arrest occurred prior to cooling (LOE 6), hy-
pothermic cardiac arrest is prolonged (LOE 3), and ad-
Knowledge gaps vanced and prolonged resuscitative efforts are less likely
to be fruitful.135, 144
Changes in blood gas parameters in clinical small ani-
mal patients undergoing CPR have not been investigated
and the value of blood gas analysis during CPR has not Knowledge gaps
been examined. Such studies are necessary. In addition,
The occurrence of electrolyte abnormalities over the
acquisition of more experimental data, for example, in
course of CPA and CPR has not been described in clinical
asphyxial cardiac arrest models, is warranted prior to
veterinary medicine, nor have the effects of electrolyte-
recommending the measurement of venous blood gas
directed therapy been tested. Efforts should be under-
data in clinical patients.
taken to identify and investigate subsets of patients with
these abnormalities to further define clinical approaches.
Monitoring electrolytes during CPR (MON21)
PICO Question
Prediction of defibrillation success from VF waveform
In dogs and cats with cardiac arrest (P), does the mea- (MON24)
surement of arterial or venous electrolytes (Na+ , K+ ,
PICO Question
Ca2+ ) during resuscitation (I) versus not measuring elec-
trolytes (C) improve the chances of ROSC (O)? In dogs and cats with cardiac arrest (P), does the use of
a technique for prediction of the likelihood of success
of defibrillation (analysis of VF, etc) (I), compared with
Conclusion
standard resuscitation (without such prediction) (C), im-
In cases where the cause of cardiac arrest may be due prove outcomes (eg, successful defibrillation, ROSC, sur-
to electrolyte abnormalities (eg, hyperkalemia), the mea- vival) (O)?
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RECOVER monitoring
Conclusion Knowledge gaps

Based on laboratory investigations in dogs and swine, Waveform analysis has not yet been evaluated in vet-
coarse VF is more likely to respond with ROSC following erinary medicine. However, more sophisticated defibril-
defibrillation than fine VF. Waveform analysis that can lators with data acquisition and review capability will
predict defibrillation success, however, remains a topic allow for ECG waveform analysis to fill that gap.
of investigation. Due to the small number of randomized
clinical trials in human medicine, and the complete lack
of clinical trials in veterinary medicine, it is uncertain The role of EtCO2 in identification of ROSC (MON10)
whether these techniques will improve clinical outcomes PICO Question
in dogs and cats with CPA. In dogs and cats in cardiac arrest (P), does the use of
EtCO2 (I), compared with clinical assessment (C), im-
prove accuracy of diagnosis of a perfusing rhythm (O)?
The gold standard in determining the likelihood of re-
Conclusion
sponse to defibrillation is measurement of the CPP.145, 146
Even in human medicine, the difficulties associated with Only 1 study described an association between EtCO2
arterial and central venous cannulation during CPR has and clinical assessment (auscultable heartbeat) during
led to investigations of other means for prediction of CPR and suggested in a neonatal pig model that an in-
defibrillation success. crease in EtCO2 over 14 mm Hg should prompt eval-
Newer techniques focus on ECG waveform analysis. uation for return of a heartbeat. Many clinical and ex-
These techniques investigate the VF wavelets for compo- perimental studies describe a marked increase in EtCO2
nents that indicate a high chance of successful defibril- upon ROSC. Given the clinical difficulty that may be as-
lation if a counter shock is administered. The VF wave- sociated with auscultation during CPR, the presumed
form changes from a higher amplitude wavelet (coarse negative effects of CPR interruptions for auscultation or
VF) during the initial phase of untreated VF (less than ECG review, and the difficulties differentiating PEA from
3-4 minutes of duration) to a lower amplitude wavelet a perfusing rhythm, EtCO2 monitoring may improve di-
(fine VF) with the progression in time (LOE 6).147 As the agnosis of ROSC.
amplitude and structure of the VF waveform decreases,
there is a decreased likelihood of ROSC and survival
(LOE 3 and 6).147, 148 Waveform analysis can also esti-
mate the duration of VF, which guide timing of electrical Chalak et al examined the association between EtCO2
defibrillation. readings and physical examination parameters in a
CPR generates significant ECG artifacts that com- piglet CPR study (LOE 6).156 The objective was to de-
plicate VF waveform analysis. Techniques (all LOE termine the EtCO2 level that best predicted the return of
6) including amplitude spectrum area transformation an audible heart beat, for purposes of minimizing inter-
(AMSA)149–152 and scaling exponents153 have been ap- ruption of chest compressions during CPR. The authors
plied to summarize the ECG waveform. Due to the com- studied 46 anesthetized piglets in an asphyxiation model
plexity of these methods, their clinical utility has been of CPA. The piglets underwent CPR with continuous
restricted to more sophisticated AED’s. AMSA analy- EtCO2 monitoring, while auscultation was performed
sis has been used to identify suboptimal chest compres- every 30 seconds. An EtCO2 value of 14 mm Hg had a
sions, and may be factored into AED-based prompts for sensitivity of 93% and a specificity of 81% for prediction
bystander CPR (LOE 6).152 of the presence of an audible heartbeat. Bhende et al re-
Human studies to date have focused on the use of ported a sharp increase in EtCO2 values at the onset of
waveform analysis to determine the duration of VF, and ROSC in an experimental canine study (LOE 3), but did
to investigate the subsequent question of whether a short not compare this to clinical assessment.44
period of CPR prior to counter shock is beneficial in pa-
tients with certain durations of VF. Randomized clinical
Knowledge gaps
trials in humans (LOE 6) to determine if waveform anal-
ysis and CPR prior to counter shock improved outcomes There is a paucity of studies evaluating the use of
have not shown any survival benefit to a short period of EtCO2 monitoring for prediction of ROSC in veterinary
CPR prior to counter shock.154, 155 However, one of the medicine, with much of the available data consisting of
studies found a potential survival benefit for pre-shock experimental studies directed toward human CPA and
CPR in patients with prolonged (>5 minutes) VF.154 CPR (ie, the use of asphyxiation or VF models), rather

Brainard et al.
than naturally occurring CPA and clinical CPR in an- citation have yet to be determined in dogs and cats. Evi-
imals. More research evaluating EtCO2 monitoring in dence from the human literature suggests that episodes
conjunction with the clinical assessment of patients and of hypotension following ROSC are associated with a
the use of other monitors may help to define and improve worse outcome, so it is reasonable to measure blood
the prompt diagnosis of perfusing rhythms in veterinary pressure continuously whenever possible to recognize
CPR. and prevent hypotension. Given the occurrence of my-
ocardial dysfunction in humans and animals (even in the
absence of coronary artery occlusion) following ROSC,
Monitoring following ROSC it is also reasonable to serially monitor veterinary CPA
After spontaneous circulation is reestablished, physio- patients with continuous ECG and echocardiography.
logic monitoring devices to which clinicians are accus- Continuous oximetry may be useful to guide titra-
tomed, such as pulse oximeters and noninvasive blood tion of inspired oxygen concentrations to prevent both
pressure monitors, regain their functionality. The postre- hypoxemia and hyperoxia. The actual targets for ar-
suscitation population is extremely heterogeneous due terial oxygenation are unclear. Complications such as
to variability in duration and conditions of arrest, precip- pulmonary edema, pneumonia, and pulmonary contu-
itating diseases, and other factors. Moreover, each time sions are not uncommon following CPR and veterinary
phase after ROSC demands different monitoring char- patients should be monitored for hypoxemia by pulse
acteristics as the goals of therapy shift from prevention oximetry and/or arterial blood gases. There is evidence
of rearrest immediately after ROSC to treatment of pre- that the PaCO2 -EtCO2 difference may be associated with
cipitating disease and the consequences of anoxic brain outcome in people following ROSC and measuring ar-
injury, cardiac dysfunction, and global reperfusion injury terial blood gases and EtCO2 would be reasonable in
once stable ROSC is established.157 These monitoring de- ventilated veterinary patients following ROSC.
vices may also provide valuable prognostic information. Glucose should be monitored serially to detect hypo-
Much of the postcardiac arrest monitoring follows prin- glycemia and hyperglycemia. It seems prudent to avoid
ciples customary to veterinary critical care. Additional iatrogenic hyper- or hypoglycemia, and preliminary ev-
specific postcardiac arrest monitoring considerations are idence in people (LOE 6) suggests that the severity of
the focus of MON 25. hyperglycemia in the postcardiac arrest phase is corre-
lated with a worse outcome. Induced mild therapeu-
tic hypothermia in humans that remain comatose after
The relevance of intensive continuous postcardiac ar- ROSC is rapidly becoming standard of care. Worse out-
rest monitoring (MON25) come has been described in people that have episodes
PICO Question of hyperthermia. Similarly, the severity of accidental hy-
pothermia present at ROSC was associated with worse
For dogs and cats with ROSC after cardiac arrest (P), does outcome. Serial monitoring of rectal or core temperature
the use of intensive continuous monitoring (eg, contin- in veterinary patients after ROSC is reasonable. Seizures
uous ECG, blood pressure, temperature, pulse oximeter, are not uncommon in people following ROSC and may
±EtCO2 ) (I) versus standard intermittent monitoring (C) be associated with a worse outcome. It is therefore rea-
improve outcome (eg, survival)? sonable to include monitoring for seizures and changes
in neurologic status in veterinary patients with ROSC.
There is evidence in support of serial monitoring of
Conclusion
ECG, arterial oxygenation, body temperature, blood glu-
Veterinary studies evaluating monitoring as it relates to cose, and systemic blood pressure following ROSC, in
outcome following ROSC are lacking, and therefore any addition to serial physical exams and neurologic moni-
recommendations for intermittent or continuous monitoring. There is no clear evidence to delineate between
toring following ROSC must be drawn from the human recommendations for continuous monitoring versus in-
literature. Recommendations for monitoring after ROSC termittent monitoring of these variables, and this should
in the human literature tend to be extrapolated from be tailored to individual patients and circumstances, es-
studies in other shock states or based on expert opinion. pecially when determining the intervals for intermittent
Although not supported by prospective research, monitoring.
there is a current trend toward early goal directed ther-
apy (EGDT) in postcardiac arrest patients following
ROSC. EGDT aims to establish early hemodynamic sta-
bility and adequate oxygen delivery parameters, a logi- After achieving ROSC, patients can enter a systemic in-
cal goal in patients following ROSC. Endpoints for resus- flammatory state not unlike SIRS or sepsis.158, 159 Early
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RECOVER monitoring
optimization of systemic oxygen delivery has been sub- tween survivors and nonsurvivors, with nonsurvivors
sequently applied to postcardiac arrest patients (LOE having significantly elevated Vd /Vt and PaCO2 -EtCO2
6), with recommendations for monitoring arterial blood differences compared to survivors.
pressure, central venous pressure, serum lactate, arte- Oxygen therapy continues to be recommended in hu-
rial and central venous oxygen saturation, and cardiac man CPR guidelines during resuscitation, as well as
output.158, 160,161 However, these studies were not de- during the post-cardiac arrest care phase. However, hy-
signed to examine the value of individual monitoring peroxemia has been associated with brain injury, worse
elements or interventions, but rather the impact of the neurologic outcomes, and increased mortality in swine
entire treatment package. There is very limited direct ev- (LOE 6), dogs (LOE 3), and people (LOE 6).165, 172,173
idence in the human or veterinary literature to support Oximetry-guided reoxygenation following ROSC has
or refute continuous or intermittent monitoring in the been associated with improved neurological outcomes
postcardiac arrest phase. in dogs (LOE 3).173 This prospective randomized experi-
Several indications exist for the use of continuous mental study in 17 dogs, using continuous pulse oxime-
or intermittent ECG following ROSC. Arrhythmias are try followed by blood gas analysis, demonstrated im-
commonly encountered in humans following ROSC proved neurologic function and less histologic brain in-
(LOE 6) such that continuous ECG monitoring is injury in the animals with oxygen administration titrated
cluded in most human postcardiac arrest monitoring to an SpO2 of 94% to 96% within 12 minutes of ROSC,
guidelines.162–164 In addition to identifying cardiac ar- when compared to dogs maintained on 100% O2 .
rhythmias, continuous ECG monitoring has been used Seizures are common during the postcardiac arrest
to assess postresuscitation heart rate variability, a metric phase in humans, and human clinical studies suggest
suggestive of autonomic nervous system function (LOE that patients experiencing seizures in the first 24 hours
6).159, 163 following ROSC have a worse long-term neurologic out-
Manipulation of mean arterial blood pressure (MAP) come (LOE 6).162, 174
following ROSC is an area that has received consider- There is strong experimental and human clinical ev-
able attention in the human literature, although specific idence that induced hypothermia following ROSC re-
MAP goals have not been determined. Recent research sults in favorable outcomes and which suggests worse
(LOE 6) has demonstrated a worse outcome with the oc- outcomes following hyperthermia in postcardiac arrest
currence of episodes of hypotension in the first 6 hours patients.174–180 Interestingly, an episode of passive hy-
after ROSC.160, 165,166 However, another study (LOE 6) pothermia following ROSC resulted in a decreased odds
evaluating blood pressure over a longer time period of survival to hospital discharge (LOE 6).176
(24 hours) failed to show such an association.167 MAP Optimum blood glucose values in people have
target values have varied among studies and ranged not been determined for patients with ROSC. Hy-
from 65 to 100 mm Hg. The optimal arterial blood pres- perglycemia occurring in the first 24–72 hours after
sure following ROSC has not been conclusively deter- ROSC was associated with a worse outcome (LOE
mined. Three human studies reported that early lactate 6).162, 174,181, 182 A retrospective study in a human postcar-
clearance after resuscitation from cardiac arrest was as- diac arrest population (LOE 6) showed that patients with
sociated with reduced mortality (LOE 6).160, 161,168 Re- moderate-to-severe hyperglycemia did poorly; however,
versible myocardial dysfunction, also known as my- those with mild increases in glucose had a similar out-
ocardial stunning, has been documented in animals and come as those with normal glucose values.183
people following ROSC and has been associated with
Knowledge gaps
lower survival rates in 1 clinical study (LOE 6).169 A
prospective study including 87 people that were success- In 1 veterinary study, 54% of animals who achieved
fully resuscitaed from in-hospital cardiac arrest found ROSC succumbed to another episode of CPA, highlight-
a 25% reduction in left ventricular ejection fraction in ing the importance of postcardiac care and monitoring.18
the postcardiac arrest phase when compared to prearrest Studies are required to evaluate the need for strict control
values (LOE 6).170 Left ventricular dysfunction was as- of body temperature, blood glucose, arterial oxygena-
sessed with transthoracic echocardiography, which was tion, and hemodynamic metrics, such as MAP, lactate,
shown to also be useful in guiding postcardiac arrest and central venous oxygen saturation in dogs and cats
fluid therapy.171 after cardiac arrest.
A prospective observational study (LOE 6) evaluated
PaCO2 -EtCO2 difference and alveolar dead space ven-
Discussion
tilation ratio (Vd /Vt , where Vd is alveolar dead space
volume) in mechanically ventilated patients 1 hour fol- Taken together, the evidence evaluated and pre-
lowing ROSC.160 A significant difference was found be- sented here suggests that the monitoring of end-tidal

Brainard et al.
capnography may be useful for evaluation of the degree of conviction, and influencing factors Acad Emerg Med.
2004; 11(8):878–880.
strength of, quality of, and physiologic response to chest 8. Tibballs J, Weeranatna C. The influence of time on the accuracy
compressions during CPR, for indicating ROSC, and pos- of healthcare personnel to diagnose paediatric cardiac arrest by
sibly as a prognostic factor in animals with CPA. On pulse palpation Resuscitation. 2010; 81(6):671–675.
9. Albarran JW, Moule P, Gilchrist M, et al. Comparison of sequential
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are needed to evaluate the diagnostic, prognostic, and 11. Sayre MR, Koster RW, Botha M, et al. Part 5: adult basic life
support: 2010 international consensus on cardiopulmonary re-
monitoring utility of EtCO2 measurement in small ani- suscitation and emergency cardiovascular care science with treat-
mal CPR, but wider distribution of this technology will ment recommendations Circulation. 2010; 122(16 Suppl 2):S298–
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flow during CPR JACEP. 1978; 7(5):180–185.
MON03, it is easier to diagnose a heartbeat than a lack of 15. Lichti EL, Willets P, Turner M, et al. Cardiac massage efficacy
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Journal of Veterinary Emergency and Critical Care 22(S1) 2012, pp S65–S84

Special Article doi: 10.1111/j.1476-4431.2012.00751.x

RECOVER evidence and knowledge gap

(J Vet Emerg Crit Care 2012; 22(S1): 65–84) doi: 10.1111/j.1476-4431.2012.00751.x

Keywords: cardiac arrest, CPR, evidence

CPA cardiopulmonary arrest

Summary of the evidence perienced a cardiac arrest. In addition to assessment of

Conclusion The value of EtCO2 for diagnosing CPA (MON02)

Knowledge gaps Knowledge gaps

were not in accordance with guidelines failed to show a Summary of Evidence

Conclusion Knowledge gaps

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