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With veterinary medicine offering ever higher levels of care, allowing sicker patients to be treated, witnessing cardiopulmonary arrest is not uncommon in practice and veterinary practitioners and their support staff should be ready to perform cardiopulmonary resuscitation (CPR). However, while hands-on training in veterinary CPR techniques is increasingly available, less emphasis has been placed on the importance of preparation at a practice level so that CPR can be initiated without delay. This article discusses some of these practical preparations and the importance of training the veterinary team to deliver effective CPR if needed.

IN a recent prospective study, McIntyre and others (2014) evaluated factors associated with the outcome of in-hospi-tal cardiopulmonary resuscitation (CPR) in dogs and cats. They found that 58 per cent of patients attained return of spontaneous circulation (ROSC) but only 5 per cent were discharged alive from the hospital. In comparison, statis-tics published by the American Heart Association indicate that, in 2016, the survival rate (to hospital discharge) in human adult patients undergoing in-hospital CPR was 24.8 per cent (AHA 2016). Although many factors – includ-ing the actual cause of cardiac arrest and veterinary or human medical training (with the latter being more speci-ality specific) – play a role in generating this discrepancy, it is still undeniable that CPR (and post-CPR care) can and must be improved in small animal patients.

In 2012, the RECOVER (REassessment Campaign On VEterinary Resuscitation) Initiative presented a series of evidence-based consensus guidelines for veterinary CPR in cats and dogs (Fletcher and others 2012). These guide-lines cover CPR-related topics in five domains: ■■ Preparedness and prevention;■■ Basic life support;■■ Advanced life support; ■■ Monitoring;■■ Post-cardiac arrest care.

During the course of the RECOVER Initiative, major knowl-edge gaps were identified in many variables around car-diopulmonary arrest (CPA) and the success of CPR and the need for further studies was emphasised.

Training and preparationSeveral differences between human CPR and veterinary CPR come to mind, including the level of monitoring and postoperative care available to patients, but a factor that is too often overlooked is the difference in training received by people performing CPR in human patients and those in the veterinary world. When CPR is taught in veterinary courses or conferences, most attention is natu-rally directed to basic and advanced life support; some is focused on post-CPR care, but very little is said about the importance of being prepared and effectively trained to perform CPR.

There is evidence from the human literature (Hoadley 2009) that training for CPR can improve patient outcome in many ways, including through better adherence to CPR guidelines.

Alessandra Mathis qualified from the University of Perugia in Italy in 2003 and worked in general veterinary practice in Italy for three years. Having developed an interest in anaesthesia, she undertook an internship and then a three-year residency in anaesthesia and analgesia at the Royal Veterinary College in London during which time she gained the RCVS certificate in veterinary anaesthesia. She joined Willows Veterinary Centre and Referral Service in 2011 and became a Diplomate of the European College of Anaesthesia and Analgesia in 2012.

Preparing and training for CPRAlessandra Mathis

doi: 10.1136/inp.k5125

Therefore, preparation for CPR therefore includes not only the process of setting up a ’ready’ area where basic and advanced life support will be performed, but also ensuring personnel training and debriefing after any CPA or CPR (real or booster practical training session) effort has occurred. Optimising patient outcome requires a coordinated team with in-depth knowledge of the lat-est CPR guidelines, tidy, organised and functional equip-ment, and the ability to provide 24/7 post-ROSC care.

‘Ready’ areaAny delay in starting CPR is associated with significant reductions in survival to discharge from hospital and with neurological status decay (Fletcher and others 2012). Having an area of the practice that is always ready, organ-ised and functional for CPR will facilitate its initiation in a timely manner.

If a practice does not have an intensive care unit (ICU), this ‘ready’ area will often be the prep room or wherever the endotracheal tubes are stocked and readily avail-able alongside kits to place intravenous (IV) cannulas and administer IV fluids. An easily accessible, organised crash trolley (Fig 1a, b, c) is the preferred option but, due to space restrictions, in most practices a crash box is adopted (Fig 1d). When the latter is used, it should con-tain only drugs and equipment that are not quickly reach-able in the crash area (Table 1). If too much is stocked in a small box then it is difficult for it to be organised and valuable when it is needed. A compromise could be to use a plastic tower storage unit and label the different draw-ers as seen in Fig 1e.

The most frequent cause of equipment-related delay in initiating CPR is missing equipment (failure to return it after use, incomplete stocking, etc). Therefore, equip-ment and supplies must be prestocked and regularly audited (Fig 1f). Sealing the box or trolley (Fig 2) can help ensure that supplies are available and used only if needed.

Other factors that can also result in equipment-related delays include: ■■ Basic device failure, such as intrinsic design faults; ■■ External factors, such as power supply failure; and■■ Human error, such as an inability to use specific instru-

ments. Staff must be familiar with the crash trolley or box (Fig 3) and must be trained in using the related equipment (such as the defibrillator) .

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StandardisationIf there are several areas in the same practice or hospital where CPR may be performed (eg, the ICU and the prep room), the crash trolleys/boxes in each area should con-

tain the same equipment in the same places, as this will minimise delays in finding the correct piece of equipment or drugs. Ideally, if multiple defibrillators are present, these too should be similar so as to diminish the need to learn how different equipment works.

ChecklistsChecklists and drug dosing charts are also very use-ful timesavers. Longer, more comprehensive, check-lists have been shown to improve outcome over shorter checklists or no checklists at all (Ward and others 1997). Unfortunately, checklists are still rarely used in CPA situ-ations. Bould and others (2009) found that the reasons for this include: lack of clarity of checklists; believing that checklists are unnecessary; lack of specifics; time pres-sure; unfamiliarity; difficulty of using a checklist in the middle of a CPR scenario; and disagreement with the con-tent of a checklist.

The 2012 RECOVER guidelines (Fletcher and others 2012) contain a number of useful checklists and charts, includ-

Fig 1: (a) A readily accessible crash trolley, with (b, c) all the required equipment organised in separate compartments helps to ensure CPR can begin without delay. Alternative options include (d) a crash box or (e) a plastic tower-style storage unit, with each drawer labelled. (f) Regardless of the option chosen, the equipment and supplies should be regularly audited

Fig 2: Sealing the crash trolley or box can ensure that equipment and supplies are not used for other purposes and then not returned or restocked

(a)

(f)

(b) (e)

(d)

(c)

Fig 3: Staff must be familiar with the crash trolley or box and must be trained in using the related equipment

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ing an algorithm delivering step-by-step prompts to the veterinary rescuer during CPR and summarising the most relevant clinical guidelines. A post-cardiac arrest algo-rithm is also available, summarising a comprehensive treatment protocol for post-cardiac arrest care. Finally, a CPR emergency drugs and doses chart provides a quick reference tool, with the drugs separated by indication (arrest drugs, antiarrhythmic drugs, reversal drugs and

defibrillation energy) and the volumes required provided by bodyweight to help reduce calculation errors in stress-ful situations. However, before using this chart, veterinary professionals should check that the concentrations of the drugs in the chart correspond to those of the drugs in use in their practice.

All of these algorithms and charts can be freely download-ed via www.acvecc-recover.org and could be hung on the crash trolley or kept in the crash box (Fig 4).

DrugsAccording to the RECOVER guidelines, during the first two-minute cycle of CPR, drugs such as adrenaline should not be administered and only basic life support should be per-formed. Depending on the rhythm identified on the ECG at the end of the first cycle, adrenaline, lidocaine or atropine may be administered during the second two-minute cycle.

Some institutions prefer to have drugs preloaded into syringes and these are then discarded every week/month. The decision to preload syringes may be based on the number of staff available during CPR – if enough peo-ple are present then, to minimise wastage, drugs can be drawn up during the first cycle of CPR. However, if, at any time of the day, there are fewer than three people in the practice available to perform CPR, it would be advisable to preload drugs into syringes.

The stability of lidocaine and adrenaline in polypropylene syringes has been demonstrated for up to 90 days (Storms and others 2002, Rawas-Qalaji and others 2009), hence it would be advisable to store these for no more than a few months.

Data concerning atropine stored in polypropylene syringes are slightly less clear, with some studies show-ing a 50 per cent decrease in atropine concentration by day 3 (Lewis and others 1994) while others suggest that atropine is stable for up to eight days when stored into polypropylene syringes (Driver and others 1999).

In the light of these studies, it would be recommended to discard preloaded atropine every week.

Table 1: Crash box/trolley contents* Contents Comments

Endotracheal tubes (ETT) – various sizes

The number of ETT depends on the size of the box/trolley and on the availability of ETT in the proximity of the box/trolley. Small diameter tubes should be long enough to be used in brachycephalic dogs or larger patients with upper airway obstruction

Laryngoscope and various size blades

Tie for ETT

Cuff syringe To cuff the ETT

Urinary catheter and 3 mm ETT connector

Used for difficult intubation or to insufflate oxygen

Face masks – various sizes In case intubation fails or to follow tracheal extubation

Intravenous (IV) cannulas – various sizes

Several cannulas of the same size should be available as it is not always possible to place an IV cannula at first attempt in a patient in cardiopulmonary arrest

T connectors

Injection bungs

Tape

Hibi scrub/spirit

Swabs

Syringes – various sizes Some of these can be preloaded with drugs

Needles – various sizes

Labels for syringes Or a marker-type pen to write on the syringes

Drugs – Adrenaline – Atropine – Lidocaine – Noradrenaline – Atipamezole – Naloxone – Flumazenil

Ideally only one concentration should be available

Without adrenaline

To antagonise alpha-2-agonistsTo antagonise opioidsTo antagonise benzodiazepines

Flush Saline or hep-saline. A relatively large volume of fluid is needed to ‘push’ the drug from the IV cannula to the central compartment

ECG pads/clip

Fluids – Hartmann’s – Saline – Hypertonic saline – Mannitol – Colloids

Giving sets Including giving sets with filters if mannitol is stocked

Spinal needles/large bore needles For intraosseous access

Large syringe and suction tip/urinary catheter

If suction not readily available

Drug dose chart Hanging on the box or wall in the proximity of the box

Cardiopulmonary resuscitation (CPR) algorithm

Hanging on the box or wall in the proximity of the box

CPR record

Calculator

Pens

Timer To keep track of the two-minute cycles

Sand bag To help stabilise the patient during chest compressions

* The contents will vary according to the size of the box/trolley and the availability of drugs/equipment in close proximity to where CPR is performed

Fig 4: A CPR algorithm and crash drugs chart should be readily available with the crash trolley or box

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Personnel trainingHigh-quality basic life support consists of early recognition of CPA and administration of two-minute cycles of chest compressions and ventilation. The compressions must be of adequate rate and depth, with the giver’s hands and the patient properly positioned, and the ventilation pro-vided must be adequate. Performing basic life support in an effective, organised manner requires both cognitive and psychomotor skills. In fact, the RECOVER guidelines state that ‘CPR training should be targeted at both cognitive per-formance and hands-on practice with quality feedback.’

LeadershipThe CPR team should be structured and should have a clear leader. In human medicine, there is no evidence that a more experienced team leader (ie, medically trained or not) improves the success of CPR (Olasveengen and oth-ers 2009) but there is compelling evidence, at least in simulation scenarios, that specific leadership training will improve CPR performance.

Leadership itself is difficult to describe but the main role requisite is being able to adapt and to coordinate tasks that change during the resuscitation process. Leadership skills can be better performed if an observing and coordi-nating role, rather than a hands-on role, is adopted during CPR. This will allow the leader to have a broader view on the situation and think about the steps required.

The leader’s first responsibility is, of course, to estab-lish leadership. Following this, team members should be given roles as they arrive and, at the same time, basic life support should be implemented. The leader must also maintain a global perspective of the situation and ensure that the CPR guidelines are properly followed, prompting cooperation among the team members and minimising interruptions. The leader should step down and quickly and efficiently hand over leadership if a more competent individual becomes available to take over (Tschan and oth-ers 2014).

Successful leaders are extrovert, self-confident, flex-ible, calm and interested in improving team performance through training. These are the traits leadership training should aim to develop (Graham and others 2015).

Team trainingTeam training on CPR techniques must be standardised as this has been shown not only to improve success rates but also the feeling of competence in individuals perform-ing CPR (McMichael and others 2012). In recent years, the awareness of CPR guidelines and the importance of hands-on training has been raised through teaching in vet schools and at conferences, as well as by recognised spe-cific veterinary online courses.

In training for human CPR, high-fidelity manikins and other feedback devices have improved the initial learning of some of the psychomotor skills. These are not read-ily available for the veterinary market but some CPR dog manikins can be found. In these manikins, it is possible to place IV cannulas, intubate the trachea (Fig 5), inflate the lungs with ventilation and palpate femoral pulses. The most advanced manikins also have a light system indicat-ing correct ventilation and compression pressure and correct hand position for chest compressions or beeps indicating excessive pressures.

Non-cognitive skills that should be taught during team training include clear closed-loop communication and standardised crash calls and cross-checks to ensure, for example, that other team members are clear of a patient before defibrillation.

Booster trainingIn addition to initial CPR training, booster training is rec-ommended to avoid deterioration of acquired skills. In fact, it has been shown that competency in CPR skills starts to deteriorate within weeks of learning, returning to pretraining levels within one to two years.

The RECOVER Initiative recommends refresher training at least every six months. Impromptu practice sessions (Fig 6) and refresher sessions using high-fidelity manikins can help to prolong the retention of psychomotor skills (Wik and others 2002).

In practices where a high-fidelity simulator is not availa-ble, simple simulations that run every three to six months on low-fidelity manikins will still improve the retention of CPR skills.

Performance assessmentA structured performance assessment is recommended after every CPR training or refresher session. It has been shown that testing at the end of a resuscitation skills course for medical students increases learning outcome compared to spending an equal amount of time practising the skills (Kromann and others 2009).

Fig 5: Intubating the trachea of a CPR dog manikin

Fig 6: Impromptu training sessions for all team members help them retain the required psychomotor skills

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