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November 2024
How to Save a Life
This year, RECOVER released its first major revisions to its CPR guidelines for basic life support, advanced life support, and monitoring. RECOVER is also the first veterinary organization to use an even more rigorous method known as GRADE.
Updated RECOVER CPR Guidelines Help You React with Confidences
A dental procedure under general anesthesia is under way. The feline patient’s electrocardiogram suddenly goes from normal sinus rhythm to asystole with no electrical activity on the monitor. What do you do?
For Erin Glover, PhD, CVT, of Portland, Oregon, it was automatic.
She listened for heart sounds and palpated for a pulse, both absent, and alerted the doctor—all in about 10 seconds—initiating the cardiopulmonary resuscitation (CPR) protocol.
To someone outside of veterinary medicine, it may be difficult to understand what the big deal is. Surely there is a recognized veterinary CPR standard and mandatory certification, right?
Surprisingly, no.
And that can factor into whether a pet survives cardiopulmonary arrest.
Trying to help fill that gap has been the work of the Reassessment Campaign on Veterinary Resuscitation (RECOVER) Initiative. Its first guidelines, published in 2012, gave veterinary professionals information for five domains (basic life support, advanced life support, monitoring, preparedness and prevention, and post-cardiac arrest) to help an animal survive an emergency situation as well as the training and certification to put it into practice.
On June 26, RECOVER released its first major revisions to the CPR guidelines for basic life support, advanced life support, and monitoring. RECOVER is also the first veterinary organization to use an even more rigorous method known as GRADE. The Grading of Recommendations, Assessment, Development, and Evaluation system is the same one used by many human healthcare organizations around the world to provide a standardized approach for grading the quality of evidence and strength of recommendations.
New Information Means Changes
Why the update?
“Science changes. New information becomes available,” explained Daniel Fletcher, PhD, DVM, DACVECC, cochair of the RECOVER executive committee.
“Our goal in 2012 was to update the guidelines every five years. We went a little longer than that. We also wanted to use the more robust GRADE process rather than just tweak the work done before. We thought it would make a lot more sense to redo everything using this new process and then, moving forward, do smaller updates using that same process.”
Asked for a few of the changes and the reasons behind them, Fletcher offered these:
A better approach to chest compression in cats and small dogs under 15 pounds.
“We used to recommend chest compression the same as used on larger dogs but that could cause injuries and risk overcompression,” Fletcher said. “There are now three new recommendations for working on such patients.”
Added emphasis on early ventilation.
Fletcher pointed out that dogs and cats have more respiratory arrests than humans.
Removing high-dose epinephrine from the guidelines.
“In the old guidelines, if animals had CPR that lasted for more than 10 minutes, we suggested that they could try high-dose epinephrine,” Fletcher said. “Evidence shows that you may get a pulse back in that patient but the patient is less likely to survive to discharge. Low-dose epinephrine is still recommended for patients with nonshockable arrest rhythms.”
Updated dosing of electrical defibrillators.
“We now recommend shocking them once,” Fletcher explained. “If that doesn’t work, double the dose for the second shock and any subsequent doses. There is no more adjusting with every shock.”
Still to come are three new areas of guidelines:
- Newborns: Guidelines for newborn resuscitation of kittens and puppies born by cesarean section or through difficult labor will be published this fall. Fletcher explained that it’s “very different to resuscitate a newborn. The mortality rate is quite high. Everyone has their approach but no one has really had a robust look at what is out there in the literature and developed best practices.”
- First aid: He noted that there are a lot of first aid courses “but no one has actually gone back to the primary literature to come up with guidelines based on evidence available instead of individual experience. There is no definitive source out there for the best first aid for a dog with an arterial bleed in the leg or who has heat stroke and needs to be stabilized, for examples.”
- Large animal: New recommendations for large animals such as horses, sheep, and cattle. The latter two recommendations will be published within a year.
Not all primary care facilities perform CPR on a regular basis, which makes training difficult to keep up with. Practices, however, can support their employees by having them complete the RECOVER certification training and maintenance of certification.
Positive Response Continues
The interest in standardized guidelines and training has grown tremendously since veterinary critical care specialists came together in 2010 to discuss the need for evidence-based guidelines for veterinary CPR care.
According to Bobbi Conner, DVM, DACVECC, president of the American College of Veterinary Emergency Critical Care (ACVECC), that interest then spurred the development of the RECOVER collaboration, a nonprofit program within ACVECC and Veterinary Emergency & Critical Care Society (VECCS) to provide the guidelines.
The certification training for RECOVER instructors became a joint effort between ACVECC and Cornell University College of Veterinary Medicine.
Online and in-person training helped to offload the burden from local practices, explained Conner.
“Not all primary care facilities perform CPR on a regular basis, which makes training difficult to keep up with,” said Conner. “Practices, however, can support their employees by having them complete the RECOVER certification training and maintenance of certification. In that way, in those rare instances where a life-threatening complication occurs, the team can be ready to act and know that they are providing the most up-to-date care possible,”
RECOVER offers the online courses of CPR for Veterinary Professionals (six hours); CPR for Pet Owners (one hour); Post-cardiac Arrest Care for Veterinary Professionals (90 minutes); and CPR for First Responders (90 minutes), which will be launched this fall; and in-person training with CPR Rescuer Certification for Veterinary Professionals (six hours) with the online course as a prerequisite; and CPR for Pet Owners (two hours). Certification is valid for two years.
The response continues to be positive. According to Fletcher, with the 2012 guidelines, 90,000 took the online course, 20,000 attended in-person rescue labs, and there were 70,000 downloads of the guidelines. With the recent release of the 2024 guidelines, there were already nearly 40,000 downloads a month after publication.
“We’re now updating our online course materials, Rescuer certification workshop, and Instructor certification process with the new information for the rest of the year,” said Kenichiro Yagi, MS, RVT, VTS (ECC) (SAIM), who serves as program director for the RECOVER CPR Initiative.
“We also plan to translate the guidelines and course materials into several major languages to better support our global community of veterinary professionals. I am looking forward to the day RECOVER CPR certification is considered a must-have for every corner of veterinary medicine around the world.”
There’s Always a Risk for Arrest
As a former registered nurse, Chantal Faraudo, CVT, CVPP, of Beaverton, Oregon, knows that anyone working in human healthcare is expected to have had CPR training.
Unfortunately, she noted, completing RECOVER CPR training is not yet a requirement of the American Veterinary Medical Association. To counter that, Faraudo provides pro bono RECOVER CPR training for Portland Community College veterinary technician classes so all students can be certified before they graduate.
“I’m just one person teaching students and veterinary professionals and staff. And when students return and tell me, for example, that they had two codes during their shift and both survived because of their training, that really does make a difference,” said Faraudo, a RECOVER-certified instructor since 2019.
In her previous work in general practice and emergency and critical care, Faraudo said she saw all sorts of cardiopulmonary arrest, from trauma, anaphylaxis, and severe infections to heatstroke, heart disease, and anesthesia complications. That’s why it is imperative, she said. that every person working in veterinary medicine be trained.
Empowerment, Rise in Confidence Seen
Besides the obvious benefit to patients, the training offers other advantages.
In her RECOVER CPR classes, Faraudo said, the playing field is leveled. Everyone—those new to veterinary medicine as well as board-certified specialists—equally has a say in what they see and say and can question anything, knowing that it is okay and expected, so everyone on the team has each other’s back.
“We often have 10 people in a class who don’t know each other’s name or personalities, don’t know who’s who or what’s what,” Faraudo said. “After six or seven hours of running through various scenarios, reading EKGs, using the defibrillator, and knowing how to slide into a role that needs to be covered, they are high-fiving each other and giving each other feedback. It empowers them to respond and react, to use the knowledge they have. They are all on the same page using RECOVER’s evidence-based models and a standardized algorithm.”
Glover, who enters Oregon State University’s Class of 2028 DVM program this fall, took her CPR certification and recertification classes from Faraudo. She had only praise for Faraudo’s teaching methods and use of high-tech animal models—“the real deal minus the real-life pressure.”
She also convinced four of her colleagues at Fern Hill Veterinary Care, Happy Valley, Oregon, to obtain RECOVER certification. While general practice work does not regularly see patients needing CPR, Glover explained, “we do perform many anesthetic procedures, which are never risk-free.”
She said the training has meant added confidence that she can be a leader in a high-stress situation. Informing nervous pet parents that she is RECOVER certified also helps owners feel more at ease dropping their loved ones off for anesthetic procedures.
Steve Kochis, DVM, Chief Medical Officer, said the Oregon Humane Society (OHS) requires all of its DVMs, CVTs, and clinical leadership to be RECOVER certified.
“In addition to preparation for CPR, it creates opportunities for team building, better communication, and overall improved patient care across the organization. The plan is to eventually have everyone go through the program, including the three levels of veterinary assistants.
“OHS covers all costs for certification as we feel it is important for the standard of care we practice across both our public-facing hospital and our shelter hospital. It has absolutely made a difference. While we thankfully don’t have many patients that need CPR, the medicine and the skills have been extremely helpful for all types of emergent situations, especially when patients are under anesthesia or sedation. The training also helped us up our game with organizing our crash cart and having more checklists and preprinted forms for every situation.”
A Responsibility to Continue Improving
The push to have everyone on the same page is important, explained Yagi.
“Cardiopulmonary arrest doesn’t discriminate. The RECOVER Guidelines and CPR algorithm give everyone the ability to approach CPR systematically to give the patient the best chance to survive. Knowing the current evidence-based practices in CPR gives people the confidence to act and be an active contributor to the patient’s fate. It’s a huge responsibility, and that’s why there are certification requirements in the human medical field.
“Updating the guidelines represents the ever-changing nature of what’s best for our patients,” said Yagi. “It is every veterinary professional’s responsibility to keep up with today’s standards and continue improving ourselves to help patients.”
And that cat undergoing the dental?
“Much to my relief, we achieved return of spontaneous circulation shortly after initiating lifesaving measures,” Glover said. “I was so glad that the RECOVER training I received contributed to my feline patient going home with her people that day.”
Photo credits: vchal/iStock via Getty Images Plus; gpointstudio/iStock via Getty Images Plus; Ridofranz/iStock via Getty Images Plus
Data needed to increase knowledge
Much of the epidemiological CPR data in dogs and cats has been based on observational studies in worst-case scenarios from a few academic teaching hospitals, according to Daniel Fletcher, PhD, DVM, DACVECC, cochair of the RECOVER Executive Committee. In addition, the 2012 RECOVER evidence evaluation process discovered many knowledge gaps regarding veterinary CPR.
Improving veterinary CPR care will require information—and lots of it—about the diverse veterinary population that has experienced cardiopulmonary arrest.
To that end, the RECOVER Registry Committee developed and maintains an online RECOVERY CPR registry. It contains more than 1,000 cases of cardiopulmonary arrest in dogs and cats and is growing. Hospitals interested in contributing should contact the committee.
To keep participation thorough yet relatively pain-free, a case report form was developed with an emphasis on ease of use and simplicity. The two-page downloadable form has one section that must be filled out in real time as CPR efforts are being undertaken, while the other section’s information can be recorded later.
Information about the registry, guidelines, algorithms, and charts is available at the RECOVER Initiative website, recoverinitiative.org.