1
|
Wolf J, Buckley GJ, Rozanski EA, Fletcher DJ, Boller M, Burkitt-Creedon JM, Weigand KA, Crews M, Fausak ED. 2024 RECOVER Guidelines: Advanced Life Support. Evidence and knowledge gap analysis with treatment recommendations for small animal CPR. J Vet Emerg Crit Care (San Antonio) 2024; 34 Suppl 1:44-75. [PMID: 38924633 DOI: 10.1111/vec.13389] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/22/2024] [Accepted: 04/25/2024] [Indexed: 06/28/2024]
Abstract
OBJECTIVE To systematically review the evidence and devise clinical recommendations on advanced life support (ALS) in dogs and cats and to identify critical knowledge gaps. DESIGN Standardized, systematic evaluation of literature pertinent to ALS following Grading of Recommendations, Assessment, Development, and Evaluation (GRADE) methodology. Prioritized questions were each reviewed by Evidence Evaluators, and findings were reconciled by ALS Domain Chairs and Reassessment Campaign on Veterinary Resuscitation (RECOVER) Co-Chairs to arrive at treatment recommendations commensurate to quality of evidence, risk:benefit relationship, and clinical feasibility. This process was implemented using an Evidence Profile Worksheet for each question that included an introduction, consensus on science, treatment recommendations, justification for these recommendations, and important knowledge gaps. A draft of these worksheets was distributed to veterinary professionals for comment for 4 weeks prior to finalization. SETTING Transdisciplinary, international collaboration in university, specialty, and emergency practice. RESULTS Seventeen questions pertaining to vascular access, vasopressors in shockable and nonshockable rhythms, anticholinergics, defibrillation, antiarrhythmics, and adjunct drug therapy as well as open-chest CPR were reviewed. Of the 33 treatment recommendations formulated, 6 recommendations addressed the management of patients with nonshockable arrest rhythms, 10 addressed shockable rhythms, and 6 provided guidance on open-chest CPR. We recommend against high-dose epinephrine even after prolonged CPR and suggest that atropine, when indicated, is used only once. In animals with a shockable rhythm in which initial defibrillation was unsuccessful, we recommend doubling the defibrillator dose once and suggest vasopressin (or epinephrine if vasopressin is not available), esmolol, lidocaine in dogs, and/or amiodarone in cats. CONCLUSIONS These updated RECOVER ALS guidelines clarify the approach to refractory shockable rhythms and prolonged CPR. Very low quality of evidence due to absence of clinical data in dogs and cats continues to compromise the certainty with which recommendations can be made.
Collapse
Affiliation(s)
- Jacob Wolf
- Department of Small Animal Clinical Sciences, College of Veterinary Medicine, University of Florida, Gainesville, Florida, USA
| | | | - Elizabeth A Rozanski
- Department of Clinical Sciences, Tufts University School of Veterinary Medicine, North Grafton, Massachusetts, USA
| | - Daniel J Fletcher
- Department of Clinical Sciences, College of Veterinary Medicine, Cornell University, Ithaca, New York, USA
| | - Manuel Boller
- VCA Canada Central Victoria Veterinary Hospital, Victoria, British Columbia, Canada
- Faculty of Veterinary Medicine, Department of Veterinary Clinical and Diagnostic Sciences, University of Calgary, Calgary, Alberta, Canada
| | - Jamie M Burkitt-Creedon
- Department of Surgical and Radiological Sciences, School of Veterinary Medicine, University of California, Davis, Davis, California, USA
| | - Kelly A Weigand
- Cary Veterinary Medical Library, Auburn University, Auburn, Alabama, USA
- Flower-Sprecher Veterinary Library, Cornell University, Ithaca, New York, USA
| | - Molly Crews
- Department of Small Animal Clinical Sciences, Texas A&M University College of Veterinary Medicine & Biomedical Sciences, College Station, Texas, USA
| | - Erik D Fausak
- University Library, University of California, Davis, Davis, California, USA
| |
Collapse
|
2
|
Ruggeri L, Nespoli F, Ristagno G, Fumagalli F, Boccardo A, Olivari D, Affatato R, Novelli D, De Giorgio D, Romanelli P, Minoli L, Cucino A, Babini G, Staszewsky L, Zani D, Pravettoni D, Belloli A, Scanziani E, Latini R, Magliocca A. Esmolol during cardiopulmonary resuscitation reduces neurological injury in a porcine model of cardiac arrest. Sci Rep 2021; 11:10635. [PMID: 34017043 PMCID: PMC8138021 DOI: 10.1038/s41598-021-90202-w] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/26/2021] [Accepted: 05/07/2021] [Indexed: 01/19/2023] Open
Abstract
Primary vasopressor efficacy of epinephrine during cardiopulmonary resuscitation (CPR) is due to its α-adrenergic effects. However, epinephrine plays β1-adrenergic actions, which increasing myocardial oxygen consumption may lead to refractory ventricular fibrillation (VF) and poor outcome. Effects of a single dose of esmolol in addition to epinephrine during CPR were investigated in a porcine model of VF with an underlying acute myocardial infarction. VF was ischemically induced in 16 pigs and left untreated for 12 min. During CPR, animals were randomized to receive epinephrine (30 µg/kg) with either esmolol (0.5 mg/kg) or saline (control). Pigs were then observed up to 96 h. Coronary perfusion pressure increased during CPR in the esmolol group compared to control (47 ± 21 vs. 24 ± 10 mmHg at min 5, p < 0.05). In both groups, 7 animals were successfully resuscitated and 4 survived up to 96 h. No significant differences were observed between groups in the total number of defibrillations delivered prior to final resuscitation. Brain histology demonstrated reductions in cortical neuronal degeneration/necrosis (score 0.3 ± 0.5 vs. 1.3 ± 0.5, p < 0.05) and hippocampal microglial activation (6 ± 3 vs. 22 ± 4%, p < 0.01) in the esmolol group compared to control. Lower circulating levels of neuron specific enolase were measured in esmolol animals compared to controls (2[1-3] vs. 21[16-52] ng/mL, p < 0.01). In this preclinical model, β1-blockade during CPR did not facilitate VF termination but provided neuroprotection.
Collapse
Affiliation(s)
- Laura Ruggeri
- Istituto Di Ricerche Farmacologiche Mario Negri IRCCS, Milan, Italy
| | | | - Giuseppe Ristagno
- Department of Pathophysiology and Transplantation, University of Milan, Milan, Italy. .,Department of Anesthesiology, Intensive Care and Emergency, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Via Francesco Sforza 35, 20122, Milan, Italy.
| | | | - Antonio Boccardo
- Dipartimento Di Medicina Veterinaria, University of Milan, Lodi, Italy
| | - Davide Olivari
- Istituto Di Ricerche Farmacologiche Mario Negri IRCCS, Milan, Italy
| | - Roberta Affatato
- Istituto Di Ricerche Farmacologiche Mario Negri IRCCS, Milan, Italy
| | - Deborah Novelli
- Istituto Di Ricerche Farmacologiche Mario Negri IRCCS, Milan, Italy
| | - Daria De Giorgio
- Istituto Di Ricerche Farmacologiche Mario Negri IRCCS, Milan, Italy
| | - Pierpaolo Romanelli
- Dipartimento Di Medicina Veterinaria, University of Milan, Lodi, Italy.,Mouse and Animal Pathology Lab (MAPLab), Fondazione UniMi, Milan, Italy
| | - Lucia Minoli
- Dipartimento Di Medicina Veterinaria, University of Milan, Lodi, Italy.,Mouse and Animal Pathology Lab (MAPLab), Fondazione UniMi, Milan, Italy
| | - Alberto Cucino
- Department of Pathophysiology and Transplantation, University of Milan, Milan, Italy.,Department of Anesthesiology, Intensive Care and Emergency, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Via Francesco Sforza 35, 20122, Milan, Italy
| | - Giovanni Babini
- Department of Pathophysiology and Transplantation, University of Milan, Milan, Italy.,Department of Anesthesiology, Intensive Care and Emergency, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Via Francesco Sforza 35, 20122, Milan, Italy
| | - Lidia Staszewsky
- Istituto Di Ricerche Farmacologiche Mario Negri IRCCS, Milan, Italy
| | - Davide Zani
- Dipartimento Di Medicina Veterinaria, University of Milan, Lodi, Italy
| | - Davide Pravettoni
- Dipartimento Di Medicina Veterinaria, University of Milan, Lodi, Italy
| | - Angelo Belloli
- Dipartimento Di Medicina Veterinaria, University of Milan, Lodi, Italy
| | - Eugenio Scanziani
- Dipartimento Di Medicina Veterinaria, University of Milan, Lodi, Italy.,Mouse and Animal Pathology Lab (MAPLab), Fondazione UniMi, Milan, Italy
| | - Roberto Latini
- Istituto Di Ricerche Farmacologiche Mario Negri IRCCS, Milan, Italy
| | - Aurora Magliocca
- Department of Pathophysiology and Transplantation, University of Milan, Milan, Italy
| |
Collapse
|
3
|
Roach C, Tainter CR, Sell RE, Wardi G. Resuscitating Resuscitation: Advanced Therapies for Resistant Ventricular Dysrhythmias. J Emerg Med 2020; 60:331-341. [PMID: 33339645 DOI: 10.1016/j.jemermed.2020.10.051] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/02/2020] [Accepted: 10/22/2020] [Indexed: 10/22/2022]
Abstract
BACKGROUND More than 640,000 combined in-hospital and out-of-hospital cardiac arrests occur annually in the United States. However, survival rates and meaningful neurologic recovery remain poor. Although "shockable" rhythms (i.e., ventricular fibrillation (VF) and pulseless ventricular tachycardia (VT)) have the best outcomes, many of these ventricular dysrhythmias fail to return to a perfusing rhythm (resistant VF/VT), or recur shortly after they are resolved (recurrent VF/VT). OBJECTIVE This review discusses 4 emerging therapies in the emergency department for treating these resistant or recurrent ventricular dysrhythmias: beta-blocker therapy, dual simultaneous external defibrillation, stellate ganglion blockade, and extracorporeal cardiopulmonary resuscitation. We discuss the underlying physiology of each therapy, review relevant literature, describe when these approaches should be considered, and provide evidence-based recommendations for these techniques. DISCUSSION Esmolol may mitigate some of epinephrine's negative effects when used during resuscitation, improving both postresuscitation cardiac function and long-term survival. Dual simultaneous external defibrillation targets the region of the heart where ventricular fibrillation typically resumes and may apply a more efficient defibrillation across the heart, leading to higher rates of successful defibrillation. Stellate ganglion blocks, recently described in the emergency medicine literature, have been used to treat patients with recurrent VF/VT, resulting in significant dysrhythmia suppression. Finally, extracorporeal cardiopulmonary resuscitation is used to provide cardiopulmonary support while clinicians correct reversible causes of arrest, potentially resulting in improved survival and good neurologic functional outcomes. CONCLUSION These emerging therapies do not represent standard practice; however, they may be considered in the appropriate clinical scenario when standard therapies are exhausted without success.
Collapse
Affiliation(s)
- Colin Roach
- Department of Emergency Medicine, University of California, San Diego, San Diego, California
| | - Christopher R Tainter
- Department of Anesthesiology, Division of Critical Care, University of California, San Diego, San Diego, California
| | - Rebecca E Sell
- Division of Pulmonary, Critical Care, and Sleep Medicine, University of California, San Diego, San Diego, California
| | - Gabriel Wardi
- Department of Emergency Medicine, University of California, San Diego, San Diego, California; Division of Pulmonary, Critical Care, and Sleep Medicine, University of California, San Diego, San Diego, California
| |
Collapse
|
4
|
Karlsen H, Bergan HA, Halvorsen PS, Sunde K, Qvigstad E, Andersen GØ, Bugge JF, Olasveengen TM. Esmolol for cardioprotection during resuscitation with adrenaline in an ischaemic porcine cardiac arrest model. Intensive Care Med Exp 2019; 7:65. [PMID: 31802327 PMCID: PMC6892997 DOI: 10.1186/s40635-019-0279-5] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/31/2019] [Accepted: 10/31/2019] [Indexed: 12/15/2022] Open
Abstract
Background The effectiveness of adrenaline during resuscitation continues to be debated despite being recommended in international guidelines. There is evidence that the β-adrenergic receptor (AR) effects of adrenaline are harmful due to increased myocardial oxygen consumption, post-defibrillation ventricular arrhythmias and increased severity of post-arrest myocardial dysfunction. Esmolol may counteract these unfavourable β-AR effects and thus preserve post-arrest myocardial function. We evaluated whether a single dose of esmolol administered prior to adrenaline preserves post-arrest cardiac output among successfully resuscitated animals in a novel, ischaemic cardiac arrest porcine model. Methods Myocardial infarction was induced in 20 anaesthetized pigs by inflating a percutaneous coronary intervention (PCI) balloon in the circumflex artery 15 min prior to induction of ventricular fibrillation. After 10 min of untreated VF, resuscitation with veno-arterial extracorporeal membrane oxygenation (VA-ECMO) was initiated and the animals were randomized to receive an injection of either 1 mg/kg esmolol or 9 mg/ml NaCl, prior to adrenaline. Investigators were blinded to allocation. Successful defibrillation was followed by a 1-h high-flow VA-ECMO before weaning and an additional 1-h stabilization period. The PCI-balloon was deflated 40 min after inflation. Cardiac function pre- and post-arrest (including cardiac output) was assessed by magnetic resonance imaging (MRI) and invasive pressure measurements. Myocardial injury was estimated with MRI, triphenyl tetrazolium chloride (TTC) staining and serum concentrations of cardiac troponin T. Results Only seven esmolol and five placebo-treated pigs were successfully resuscitated and available for post-arrest measurements (p = 0.7). MRI revealed severe but similar reductions in post-arrest cardiac function with cardiac output 3.5 (3.3, 3.7) and 3.3 (3.2, 3.9) l/min for esmolol and control (placebo) groups, respectively (p = 0.7). The control group had larger left ventricular end-systolic and end-diastolic ventricular volumes compared to the esmolol group (75 (65, 100) vs. 62 (53, 70) ml, p = 0.03 and 103 (86, 124) vs. 87 (72, 91) ml, p = 0.03 for control and esmolol groups, respectively). There were no other significant differences in MRI characteristics, myocardial infarct size or other haemodynamic measurements between the two groups. Conclusions We observed similar post-arrest cardiac output with and without a single dose of esmolol prior to adrenaline administration during low-flow VA-ECMO in an ischaemic cardiac arrest pig model.
Collapse
Affiliation(s)
- Hilde Karlsen
- Department of Research and Development, Oslo University Hospital, PB 4956 Nydalen, N-0424, Oslo, Norway. .,The Intervention Center, Department of Anaesthesiology, Oslo University Hospital, Oslo, Norway.
| | | | - Per Steinar Halvorsen
- The Intervention Center, Department of Anaesthesiology, Oslo University Hospital, Oslo, Norway.,Institute of Clinical Medicine, University of Oslo, Oslo, Norway
| | - Kjetil Sunde
- Department of Anaesthesiology, Oslo University Hospital, Oslo, Norway.,Institute of Clinical Medicine, University of Oslo, Oslo, Norway
| | - Eirik Qvigstad
- Department of Cardiology, Oslo University Hospital, Oslo, Norway
| | | | | | - Theresa Mariero Olasveengen
- Department of Anaesthesiology, Oslo University Hospital, Oslo, Norway.,Oslo Cardiopulmonary Resuscitation Research Network, Oslo, Norway
| |
Collapse
|