Survival with intact neurological function following cardiac arrest remains an elusive goal for resuscitation scientists worldwide, human, and animal alike. Despite the rediscovery of effective closed-chest cardiopulmonary resuscitation (CPR) in dogs more than 50 years ago and subsequent evidence-based refinements in CPR, neurologically intact survival following human cardiac arrest remains poor.[1, 2] Since 1973, animal models have been used to inform and provide “low level of evidence” support for human resuscitation consensus on science and International Resuscitation Council CPR and Emergency Cardiovascular Care Guidelines and Training Materials across 6 continents.[3] Since 1990, the development of specific, evidence-based clinical guidelines for human CPR, based upon extensive surveys of the literature by the International Liaison Committee on Resuscitation (ILCOR) has allowed consistent training for human healthcare professionals and the lay public, leading directly to improved outcomes.[4, 5] Until now, no comparable evidence-based veterinary guidelines have published, leading to challenges for implementation of standardized, comprehensive training, and variability in clinical practice and outcomes.

In this special issue of the Journal of Veterinary Emergency and Critical Care, Drs. Fletcher, Boller, and colleagues from the American College of Veterinary Emergency and Critical Care (ACVECC) and the Veterinary Emergency and Critical Care Society elegantly describe and report the findings of a heroic effort to “invert” the well-established American Heart Association (AHA) and ILCOR evidence evaluation pyramid. Using a unique and thoughtful approach adapted from ILCOR, they apply a rigorous approach to identify the science (and scientific gaps) in evidence that provide the backbone for an inaugural set of 101 clinical resuscitation guidelines for small animals (dogs and cats).[6] The guidelines are the result of a consensus process introduced at the 2011 International Veterinary Emergency and Critical Care Symposium (IVECCS) meeting, and published on the internet for public comment for a period of 4 weeks.[7]

They create consensus guidelines on Veterinary CPR and a call to arms labeled the Reassessment Campaign On Veterinary Resuscitation (RECOVER).

Although there is overlap between the literature evaluated by ILCOR and RECOVER, the science was creatively and systematically reinterpreted from a veterinary perspective, by placing a high premium on “species-specific” studies, and down-grading the level of evidence of human resuscitation trials to “extrapolation.” This “inversion” of the evidence-evaluation pyramid is novel and important. The evidence suggests that there are more similarities to the process of resuscitation in humans and animals (eg, push hard, push fast, minimize interruptions, allow full chest recoil, do not over ventilate, switch chest compressor every 2 min, monitor aggressively, use goal directed postcardiac arrest therapies, emphasize team dynamics in training), than there are differences (eg, “mouth to snout,” compress the chest in lateral recumbency).

It is clear that this heroic effort is just one of the first steps on a road full of potholes. Although there is reason to be optimistic that providing a standard for veterinary CPR practice will lead to improved outcomes for veterinary patients, evidence-based guidelines are simply not enough. The next steps of implementation with standardized training tools, registries and evaluation of outcomes, and scientific investigation to address the many knowledge gaps identified are essential. For the first time, there is a solid scientific foundation to build upon, improve, and refine. Hats off to the more than 100 contributors who fueled the RECOVER process, and onward toward RECOVER 2017!


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  2. References
  • 1
    Nichol G, Thomas E, Callaway CW, et al. Regional variation in out-of-hospital cardiac arrest incidence and outcome. JAMA 2008; 300:14231431.
  • 2
    McNally B, Robb R, Mehta M, et al. Out-of-hospital cardiac arrest surveillance—Cardiac Arrest Registry to Enhance Survival (CARES), United States, October 1, 2005–December 31, 2010. MMWR Surveill Summ 2011; 60:119.
  • 3
    Hazinski MF, Nolan JP, Billi JE, et al. Part 1: executive summary: 2010 International consensus on cardiopulmonary resuscitation and emergency cardiovascular care science with treatment recommendations. Circulation 2010;122(16 Suppl 2):S250S275.
  • 4
    Holmberg M, Holmberg S, Herlitz J. Effect of bystander cardiopulmonary resuscitation in out-of-hospital cardiac arrest patients in Sweden. Resuscitation 2000;47(1):5970.
  • 5
    Sodhi K, Singla MK, Shrivastava A. Impact of advanced cardiac life support training program on the outcome of cardiopulmonary resuscitation in a tertiary care hospital. Indian J Crit Care Med 2011;15(4):209212.
  • 6
    Fletcher DJ, Boller M, Brainard BM, et al. RECOVER evidence and knowledge gap analysis on veterinary CPR. Part 7: clinical guidelines. J Vet Emerg Crit Care 2012; 22(Suppl 1):S102S131.
  • 7
    Boller M, Fletcher DJ. RECOVER evidence and knowledge gap analysis on veterinary CPR. Part 1: evidence analysis and consensus process: collaborative path toward small animal CPR guidelines. J Vet Emerg Crit Care 2012; 22(Suppl 1):S4S12.